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f^V• 



DIFFERENTIAL DIAGNOSIS 



AND 



TREATMENT OF DISEASE 



J TEXT-BOOK FOR PRACTFTIONERS 
AND ADVANCED STUDENTS 



BY 



AUGUSTUS CAILLE, M. D. 

Fellow of the New York Academy of Medicine ; Member and ex-President of the 
American Psediatric Society ; Professor of Diseases of Children, New York 
Post-Graduate Medical School and Hospital ; Visiting Physician to 
the New York Post-Graduate and German Hospitals ; Con- 
sulting Physician to Isabella Home and Hospital, etc. 



WITH TWO HUNDRED AND TWENTY-EIGHT 
ILLUSTRATIONS IN THE TEXT 





NEW YORK AND LONDON 

D. APPLE TON AND COMPANY 

1906 



C!OPYRIQHT, 1905, BY 

D. APPLETON AND COMPANY 



PRINTED AT THE APPLETON PRESS 
NEW YORK, U. S. A. 



I 



TO 

THE MEMORY OF 

ERNESTINE AND EMMA CAILLjfi 

THIS WORK IS DEDICATED 



PREFACE 



To bring the broad domain of practical medicine fairly within the grasp 
of the family physician, and to assist the advanced student in acquiring a clin- 
ical foundation has been my aim. 

The general practitioner, representing the unity and connection of the 
various branches of medical practice, must grasp the practical details of his 
art in order to be useful at the bedside; and a book to be of value to the family 
physician should convey clinical experience without the exhaustive and often 
purely theoretical details to be found and sought for in monographs. Such 
a work I have endeavored to write. 

It has been my desire to reestablish the relations of internal medicine, 
surgery, and the several specialties; for this reason I have presented special- 
istic methods from the view-point of the general clinician. Disease is neither 
medical nor surgical nor does it hover on the border lines, but the treatment 
of disease has become more surgical and the arbitrary division into medical 
and surgical disease is no longer tenable. This unitarian principle should 
not be ignored in the presentation of disease, and many methods of diag- 
nosis and treatment originally worked out by the specialist have become, or 
should become, common property. 

Drugs no longer dominate our therapeutics; therefore the prominence 
given to hygienic, prophylactic, dietetic, hydrotherapeutic, and physical 
methods of treatment. At the same time well-tried and valuable formulae are 
distributed throughout the book. 

In prescription writing the apothecaries' weight and not the metric system 
has been used. However, simple rules for converting one into the other are 
given. 

The special chapters on the Technique of Diagnosis and Laboratory 
Aids, on Paediatrics, and the various specialties, on diseases of the Osseous, 
Muscular, and Articular System, on Nutrition and Diet, on the Management 
of Dropsy and Effusion, on Massage, Vibration, Dry Hot Air Treatment, 
Poisons and Anaesthesia, it is to be hoped will not be an unwelcome addition 
to a book on practice. Each chapter is prefaced by a synopsis of its contents 
and by brief introductory remarks on the clinical pathology of its subjects. 

In writing this book a lucid brevity in general diction has been the aim 
of the author. 

The bulk of this volume is from the author's pen. 

The chapter on Orthopaedics was contributed by Dr. C. Jaeger, Chief of 
the Orthopaedic Department of Vanderbilt Clinic, New York. 



Vi PREFACE 

My brother, Wm. Caill^, D.D.S., is the author of the Essay on the Care 
of the Teeth. Dr. R. L. Loughran has contributed Instructions for Keep- 
ing Case Records and Accounts. 

Dr. R. H. Halsey and Dr. H. B. Sheffield, both instructors in Medicine 
in the New York Post-Graduate Medical School and Hospital, have given val- 
uable aid in preparing the chapter on Infectious Fevers and Dermatological 
Memoranda. 

In revising some of the special chapters, the author has received helpful 
suggestions from Dr. H. F. Brooks, Professor of Histology and Pathology ; 
Dr. G. M. Edebohls, Professor of Gynaecology; Dr. F. Torek, Professor of 
Surgery; Dr. G. M. Schlapp, Neurologist, Cornell University; and Dr. C. 
Mund, New York Ophthalmic and Aural Institute. 

Dr. I. H. Berry has aided faithfully in arranging the manuscript, and 
my assistants in various institutions have helped to collect histories and 
original illustrations. The very excellent index is the work of Miss M. S. E. 
Cars well. 

The author tenders appreciative thanks to all who have aided in this 
undertaking. To the publishers, thanks are due for their unvarying courtesy 
and hearty cooperation during the preparation of the work. 

Augustus Caill6. 
753 Madison Avenue, New York. 



CONTENTS 



PAGE 

Introduction: The Requisites of the General Practitioner, his Relation to the Commu- 
nity and to Specialism 1 

CHAPTER I 

THE TECHNIQUE OF DIAGNOSIS AND LABORATORY AIDS TO CLINICAL DIAGNOSIS 

The technique of diagnosis 9 

Introductory remarks . 9 

The causes of disease 10 

General examination .10 

Regional examination 15 

Special examinations 16 

CHAPTER I— Concluded 

LABORATORY AIDS TO CLINICAL DIAGNOSIS 

Examination of the urine 17 

Chemical tests 19 

Microscopical examination of urine 24 

Examination of faeces 27 

Characteristics 27 

Microscopical examination of faeces 28 

Worms 30 

Clinical examination of the stomach contents 31 

Microscopical examination 32 

Chemical analysis 32 

Examination of sputum ■ .35 

Transudates, puncture fluids, cyst contents 37 

Exudates 38 

Stains 40 

Breast milk 40 

Cultures 40 

Blood 42 

Significance of hyperleucocytosis 44 

Preparation of blood slides 44 

Diseases requiring blood examination 45 

Tissue specimens 50 

Analysis of drinking water 51 

Calculi 51 

Cytodiagnosis, cytolysis, etc. 52 

Cryoscopy 54 

Phloridzin test 55 

Directions for preparing specimens 55 



viii CONTENTS 

CHAPTER II 

GENERAL THERAPEUTIC MANAGEMENT 

PAGE 

Introductory remarks 57 

Feeding in sickness 57 

Rectal alimentation — Nutrient enemata 59 

Gavage 60 

Flushing the stomach and the bowels; lavage 60 

Enteroclysis — Low and high enemata and colon inflation 63 

Antipyretic measures 64 

Drug antipyretics 65 

Hydrotherapy; balneotherapeutics 65 

Cold air 69 

Stimulation 69 

Drug stimulation 71 

General symptomatic management • .... 73 

Dyspeptic symptoms and thirst 73 

Laxatives in acute illness 74 

Diaphoretics and diuretics 74 

Expectorants and cough mixtures 75 

Inhalations 77 

Dyspnoea 77 

Pain in acute and chronic illness . . . ■ 78 

Nervousness and insomnia in the absence of pain 78 

Venesection and depletion 79 

The nasopharyngeal toilet 80 

Tonics in the convalescent stage 82 

Mental therapeutics and work for the sick 83 

Invalid bed 85 

CHAPTER III 

PAEDIATRICS 

^ Care of the new-bom 87 

^^ Points to be observed by nurses 89" 

"When children begin to walk 92^ 

-Diseases of the new-bom 92'' 

Deformities; malformations 102''' 

Infant feeding 107 

Breast feeding; maternal nursing 107 

How to nurse Ill 

Facts about milk 113 

Standard of cleanliness 113 

Rationale of milk sterilization 114 

Pancreatized milk (peptonized milk) 115 

• Diluents of cow's milk 116 

Milk laboratories and prescription writing for milk food 118 

Babcock milk tester 118 

Cow's milk for infant feeding 119 

Diet for children after weaning or during the second year of bottle feeding and 

after three years 124 

Disorders of the digestive tract 124 



CONTENTS ix 

PAGE 

Ailments of the mouth in children 126 

Mumps; parotitis 128 

Indigestion and diarrhoeal disorders 129 

Habitual constipation and difficulties of defaecatipn in infants 129 

Colic and vomiting 129 

Acute indigestion 130 

Acute catarrhal gastritis in infants 131 

Difficult feeding cases in bottle fed infants (prolonged indigestion) .... 132 

Chronic indigestion in older children 133 

Acute forms of diarrhoea 134 

Dyspeptic diarrhoea; simple diarrhoea 134 

Severe acute forms of diarrhoea 134 

Enterocolitis, or follicular enteritis 139 

Membranous enteritis, or dysentery 139 

Chronic diarrhoea 140 

Malnutrition and intestinal toxaemia (marasmus, rhachitis, scurvy) . . . 142 

Rickets, rhachitis 143 

Scurvy in children 145 

Worms in children 148 

Tuberculous peritonitis in children 149 

Diseases of the respiratory tract in children 150 

Introductory remarks 150 

Catching cold 151 

The clinical features of acute bronchitis in children 152 

Bronchopneumonia in children (catarrhal pneumonia, capillary bronchitis) . 153 
Acute lobar pneumonia in children (fibrinous, or croupous, pneumonia) . . .157 

Circulatory failure and stimulation in pneumonia 160 

Pleuropneumonia — Pleurisy with serous effusion and pyothorax in children . 160 

The significance of fever following operations for pyothorax 167 

Whooping cough; pertussis 168 

Thymus gland; enlargement and abscess 170 

Enlarged bronchial lymph nodes 171 

Diphtheria 171 

Paralysis and ataxia following diphtheria 179 

Croup 179 

Intubation and tracheotomy 183 

Disinfection of the sick room 190 

Tonsillitis, peritonsillitis; quinsy 191 

Hypertrophic tonsils in children 193 

Adenoid growths and their removal 195 

Retropharyngeal lymphadenitis and abscess 197 

Eruptive and other fevers 198 

Measles; morbilli 198 

Rubella; rotheln; German measles 200 

Varicella (chickenpox) 201 

Scarlet fever 201 

Glandular fever 206 

Malaria in children 207 

Typhoid fever in children 207 

Vulvovaginitis 208 

Masturbation in infants (thigh friction) 209 

Familiar forms of nervous derangements peculiar to early life 209 

Tics; habit spasms; paroxysmal running in children 209 



X CONTENTS 

PAGE 

Head nodding and nystagmus in rhachitic children • 210 

Night and day terrors (pavor nocturnus et diurnus) 211 

Tetany in infancy (pseudotetanus) 211 

Laryngismus stridulus (laryngospasm) 212 

Enuresis; bed wetting; incontinence 213 

Convulsions in children 214 

Chorea (St. Vitus's dance) 215 

The paralyses of infancy and childhood 215 

Meningitis in children 220 

Hydrocephalus 225 

Disorders of speech: Stammering, stuttering, and lisping 226 

Hysteria in children 226 

Mental defects from arrested developments 228 

Idiocy; imbecility; cretinism; mutism 228 

CHAPTER IV 

THE DIGESTIVE SYSTEM 

Nutrition and diet 229 

Introductory remarks 229^ 

Remarks on digestibility of food 230-^^ 

The absorption of food 230^ 

The components of food 23l«^ 

Practical dietetics: Liquid, soft, restricted, and special diet 235 

Stimulants and beverages 236^^ 

Predigested food 238-^ 

Concentrated foods 238*^ 

Systems of diet 239^ 

Vegetarianism 240^^ 

Exercise and digestion 240 

Tobacco, food, and digestion 241^ 

CHAPTER V 

THE DIGESTIVE SYSTEM — Continued 

Diseases of the mouth 242 

The care of the teeth 250 

The care and treatment of the temporary set of teeth 251 

Shedding of the temporary and eruption of the permanent set ... . 252 

Cleaning the teeth 254 

Remarks on pulpitis-periostitis, alveolar abscess, and alveolar pyorrhcea . 255 

Remarks on the emergency treatment of toothache 255 

Brief remarks on the regulation of the teeth 256 

Family type of dental deformity "256 

CHAPTER VI 

THE DIGESTIVE SYSTEM — Continued 

Diseases of the oesophagus 257 

Introductory remarks 257 

Anomalies of the oesophagus 257 

Acute inflammations of the oesophagus 258 



CONTENTS XI 

PAGE 

Chronic inflammations of the oesophagus — ^Ulcer and cancer . . . . . 258 

Stricture, paralysis, rupture, diverticulum, etc . • • 259 

Paralysis of the oesophagus . . . 261 

Rupture of the oesophagus 261 

Foreign bodies in the oesophagus 261 



CHAPTER VII 

THE DIGESTIVE SYSTEM — Continued 

Clinical pathology of the stomach and intestine and diagnostic technique . . . 262 

Remarks on the clinical pathology of the stomach 262 

Motor phenomena and neurosis 262 

Sensory phenomena of the stomach 263 

Secretory phenomena of the stomach 263 

Hydrochloric acid, HCl 264 

Digestive ferments _ 265 

Diagnostic technique 266 

Remarks on the clinical pathology of the intestine 268 

Motor phenomena 269 

Sensory phenomena 270 

Diagnostic technique 270 

CHAPTER VIII 

THE DIGESTIVE SYSTEM — Continued 

Gastrointestinal ailments in adults 273 

Acute dyspepsia; acute indigestion; gastricismus 273 

Acute gastritis, simple, phlegmonous, toxic, infectious, parasitic .... 273 

Chronic dyspepsia 274 

Clinical varieties of chronic dyspepsia 274 

Dyspepsia with dilatation or atony of the stomach 276 

Chronic nervous dyspepsia 277 

Secretory neuroses of the stomach 278 

Dyspepsia with hyperchlorhydria (hyperacidity) 278 

Erosions and ulcer of the stomach 279 

Cancer of the stomach 280 

Syphilis of the stomach . 281 

Benign tumors of the stomach 281 

Haemorrhage from the stomach 281 

Gastrointestinal neuralgia (cardialgia, gastralgia, enteralgia, colic, "stomach 

cramps") 282 

Indications for operations on the stomach 283 

Constipation; obstipation; faecal impaction 283 

Tympanites and dilatation of the colon 287 

Dilatation of the bowel, congenital and acquired 288 

Acute catarrhal enteritis 288 

Acute gastroenteritis in adults; cholera morbus 289 

Chronic enteritis 290 

Dysentery in adults 290 

Intestinal ulcer 291 

Tuberculosis of the intestine 292 



xii CONTENTS 

PAGE 

Appendicitis 292 

Diagnostic palpation of the appendix vermiformis . . , . . . 292 

Benign and malignant neoplasms of the intestine 295 

Intestinal obstruction, acute and chronic 296 

Haemorrhage from the intestines 297 

Remarks on strangulated hernia and taxis 297 

Intestinal parasites 298 

Enteroptosis; splanchnoptosis; Gl^nard's disease 300 

Intestinal putrefaction and toxaemia; autoinfection from the intestines; intestinal 

antisepsis 301 

CHAPTER IX 

THE DIGESTIVE SYSTEM — Continued 

Proctological memoranda (rectal ailments) 304 

Preliminary remarks 304 

Catarrh of the rectum; proctitis 304 

Impaction of faeces 305 

Fistula in ano 306 

Haemorrhoids (piles) . . . ' 306 

Rectal polypi 308 

Pruritus ani 308 

Prolapse of the rectum 309 

Simple fissure and ulcer of the rectum 309 

Ulceration and stricture of the rectum 310 

Neuralgia of the rectum 311 

Coccygodynia 311 

The upper rectum and sigmoid flexure 312 

CHAPTER X 

THE DIGESTIVE SYSTEM — Concluded 

Diseases of the liver 313 

General remarks 313 

Jaundice as a symptom 314 

Catarrhal jaundice in older children and adults 315 

Hyperaemia or congestion of the liver 316 

Acute yellow atrophy of the liver; malignant jaundice 316 

Cirrhosis of the liver 317 

Abscess of the liver and suppurative pylephlebitis 318 

New growths of the liver 319 

Hydatid cysts of the liver (echinococcus) 320 

Chronic degenerative processes in the liver 321 

Disease of the gall bladder and bile ducts 321 

Acute catarrh of the bile ducts (not caused by gallstones) 321 

Gallstones 321 

Cancer of the biliary apparatus 324 

Diseases of the pancreas 324 

General remarks 325 

Acute haemorrhagic pancreatitis 325 

Acute suppurative pancreatitis 325 

Tumors of the pancreas 326 



CONTENTS xiii 

PAGE 

Cysts of the pancreas 326 

Pancreatic calculus ... 328 

Diseases of the peritonaeum, omentum, and mesenteric glands 329 

Acute peritonitis 329 

Subphrenic peritonitis (abscess) 331 

Chronic peritonitis 331 

Cancer of the peritonaeum and omentum 332 

The omentum and mesentery 332 

Mesenteric and retroperitoneal glands 332 

CHAPTER XI 

THE CIRCULATORY SYSTEM 

Remarks on the clinical pathology of the circulation 333 

Congenital heart defects 335 

Clinical aspect of hypertrophy and dilatation 336 

Acute circulatory failure (heart strain, shock, collapse, rupture) .... 338 

Endocarditis, acute and chronic 339 

Pericarditis; adherent pericardium; chronic adherent pericardium .... 341 

CHAPTER XII 

THE ciRCUiiATORY SYSTEM — Continued 

Muscular and valvular insufficiency of the heart and heart neuroses . . . 344 

Weak heart; congenitally small heart; flabby heart muscle 344 

The fat-laden heart (cor adiposum) 345 

Chronic degeneration of the heart muscle not due to valvular defects . . . 346 

The senile heart and arteriosclerosis 346 

Valvular heart disease . 347 

Signs and symptoms of valvular lesions 348 

Diagnosis and prognosis of congenital heart disease 351 

Principles of treatment 351 

Visceral neuralgias in heart disease simulating other disease 355 

Neuroses of the heart 356 

Simple palpitation 356 

Arrhythmia of the heart 357 

Tachycardia (paroxysmal rapid heart) 358 

Bradycardia 358 

Spurious angina pectoris 358 

Angina pectoris 359 

Diseases of the arteries and veins 359 

Arteriosclerosis (atheroma) 360 

Phlebitis (inflammation of veins) 361 

Varicose veins 361 

Aneurysm 362 

Aneurysm of the aortic arch 362 

Aneurysm of the abdominal aorta 363 

Lymphatic system 363 

General remarks 363 

Lymphangeitis and lymphadenitis — Lymph stasis 364 



xiv CONTENTS 

CHAPTER XIII 
THE CIRCULATORY SYSTEM — Continued 

PAGE 

Conditions of the blood 368 

Terminology and definition 368 

Leucocytosis 371 

Ansemia 372 

Simple ansemia from haemorrhage 372 

Progressive pernicious ansemia 374 

Ansemia secondary to other diseases 375 

Leucaemia (leucocythsemia) 377 

Lymphatic leucsemia 378 

Diagnosis of leucsemia, treatment, etc 379 

Pseudoleucsemia 380 

Splenic anaemia 381 

Purpura and the haemorrhagic diathesis 382 

Haemophilia; haemorrhagic diathesis; bleeders 384 

Remarks on haemorrhage: external, internal, visible, invisible .... 385 

Septicaemia and pyaemia (blood poisoning) 385 

CHAPTER XIV 

THE CIRCULATORY SYSTEM — Concluded 

Clinical forms and therapeutic management of dropsy and effusion .... 387 

Anasarca; general oedema 388 

General management 388 

CEdema of the lower extremities 389 

Ascites 391 

Management of ascites 391 

Hydrothorax; pleuritic effusion 393 

Aspiration from the patient's standpoint 397 

Acute and chronic hydrocephalus; hydrencephaloid, or wet brain; cranial and spinal 

puncture 397 

Acute and subacute pulmonary oedema 399 

Collateral, or inflammatory, oedema 402 

Unilateral oedema from thrombosis and pressure 403 

Encysted dropsy; retention cysts; serous cysts 404 

Hydronephrosis 404 

Dropsy of the gall bladder 404 

Hydrosalpinx 405 

Hydrocele 405 

Serous cysts 405 

Hydatid cysts 406 

Dropsy of the amnion (hydramnios) 406 

CEdema buUosum of the urinary bladder 406 

Dropsy of joints (hydrarthros); dropsy of bursae 406 

Dropsy of tendons, tendon cysts, simple ganglion 406 

R6sum6 of diagnostic punctures 407 



CONTENTS XV 

CHAPTER XV 

THE RESPIRATORY SYSTEM 

PAGE 

The upper respiratory tract 409 

Remarks on clinical pathology of the respiratory tract 409 

Rhinological and laryngological memoranda 411 

Examination of the upper respiratory tract 411 

Autoscopy and tracheoscopy 412 

Catching cold 413 

Nasal obstruction 415 

Hyp)ertrophic rhinitis 416 

Chronic pharyngitis 416 

Chronic laryngitis 417 

Atrophic forms of rhinitis, pharyngitis, and laryngitis 418 

Erosions and ulcers in the upper respiratory tract 418 

New growths, benign and malignant, of the upper respiratory tract .... 420 

Foreign bodies in the upper respiratory tract 422 

Haemorrhage from the upper respiratory tract (epistaxis) 423 

Nasal deformities 423 

Disease of the accessory sinuses of the nose 424 

The tonsil in adults 424 

Phlegmonous amygdalitis with circumtonsillar abscess 424 

Hypertrophy of the tonsils 425 

The use of the tonsillar knife and tonsillar clipper ...... 426 

Mycosis of the pharynx and tonsils 426 

Respiratory obstruction 426 

(Edema of the larynx or glottis 426 

Neuroses and paralyses of the upper respiratory tract 427 

Vasomotor rhinitis; hay fever; pollen fever 427 

Neuroses of the pharynx 428 

Neuroses of the larynx 428 

Formulae for nose and throat treatment . . . • 429 

CHAPTER XVI 

THE RESPIRATORY SYSTEM — Concluded 

Deep respiratory tract 431^ 

Clinical features of pulmonary congestion, oedema, etc. . ._ . . . . 431'^ 

Pulmonary congestion (active, passive, hypostatic) 431"^ 

Pulmonary infarction or apoplexy 432 

Abscess of the lung 432 

Gangrene of the lung 433"'^ 

Haemorrhage from the lung (haemoptysis) 433r 

Acute forms of bronchitis in adults 434f^ 

Acute bronchopneumonia (catarrhal pneumonia; capillary bronchitis) . . . 435^ 

Acute tuberculous bronchopneumonia (hasty, or galloping, consumption) . . 437 -"^"^ 

Acute lobar pneumonia; fibrinous pneumonitis in adults 438 

Chronic forms of bronchitis and bronchopneumonia . . . . . . . 442 

Simple chronic bronchitis 442 

Chronic fibrinous bronchitis 442 

Emphysema of the lung 444 

Pneumoconiosis 445 

1 



xvi CONTENTS 

PAGE 

Bronchiectasis 446 

• Cirrhosis of the lung (chronic interstitial pneumonia) . . . . . . 446 

Chronic pulmonary tuberculosis; tuberculous bronchopneumonia; consumption; 

phthisis 446 

Bronchial asthma 457 

Acute and chronic pleurisy 460 

Dry, fibrinous, or plastic pleurisy 461 

Effusive pleurisy ; wet pleurisy 461 

Chronic pleurisy 464 

Hydrothorax; hsemothorax; pyothorax; pneumothorax 464 

Intrathoracic tumors and cysts (benign tumors; dermoid and hydatid cysts; malig- 
nant tumors) 466 

Affections of the mediastinum 468 



CHAPTER XVII 

THE GENITOURINARY SYSTEM 

Diseases of the genitorurinary organs 469 

Remarks on the clinical pathology of the genitourinary tract 469 

Systemic poisoning from kidney insufficiency 471 

Remarks on albuminuria 471 

Haematuria 472 

Hajmoglobinuria 473 

Pyuria; pus in the urine 474 

Poljoiria, oliguria, and anuria 474 

Calculi 475 

Remarks on urination, catheterism, and vesical emergencies 475 

Remarks on renal insufficiency and newer aids to diagnosis 476 

Cystoscopy, ureteral catheterism, and cryoscopy 477 

Diseases of the kidney 477 

General remarks on diagnosis 477 

Congestion of the kidneys; hypersemia of the kidneys; rupture of kidney . . 477 

Remarks on acute and chronic nephritis (Bright's disease) 478 

Acute nephritis 479 

Chronic nephritis (chronic Bright's disease) 479 

Chronic parenchymatous nephritis 479 

Chronic interstitial nephritis; cirrhosis of the kidney; contracted kidney . . 480 

The surgical treatment of acute and chronic nephritis 481 

Uraemia in nephritis 481 

Pyelitis and pyelonephritis; pyelonephrosis; surgical kidney 482 

Perinephritic abscess 483 

Movable kidney; floating kidney 484 

Summary of diagnostic points in kidney lesions 485 

The ureters 485 

Ailments of the urinary bladder 486 

Acute chronic and ulcerative cystitis and pericystitis 487 

Stone in the genitourinary tract 488 

Syphilis of the genitourinary tract 490 

Tuberculosis of the genitourinary tract 491 

Benign and malignant new growths 491 

Parasites of the genitourinary tract 492 

Localized and minor ailments of the male genital organs 492 



CONTENTS . xvii 

PAGB 

Penis 492 

Urethra 493 

Prostate 494 

Testicles and spermatic cord 495 

CHAPTER XVIII 

THE GENITOURINARY SYSTEM — Continued 

Venereal disease in the male and female, and derangements of the sexual function in 

the male 497 

Syphilis in adults and children 498 

Hereditary syphilis; congenital syphilis; syphilis hereditaria tarda .... 500 

Chancroid; soft chancre; ulcus moUe 501 

Gonorrhoea in the male and female, adult and child; remarks on its complications 

and sequelae 502 

Venereal disease in the female 505 

Functional derangements in the male 505 

Sexual erethism; masturbation; pollution 505 

CHAPTER XIX 

THE GENITOURINARY SYSTEM — Concluded 

Gynaecological memoranda 508 

Menstrual disorders 516 

Menstrual colic; dysmenorrhoea; intermenstrual pain; lumbar neuralgia . 517 

The menopause and premature menopause 518 

Incontinence of urine in the adult female 519 

Sterility in the female 519 

Vaginimus 520 

Vulvovaginal dischai^es 521 

Inflammation and abscess of the vulvovaginal glands 522 

Prolapse and malposition of the uterus and ovaries 523 

Prolapse of the uterus, ovaries, and bladder 523 

Laceration of the perinseum and cervix 524 

Ectopic gestation 525 

Pelvic ha;matocele 525 

Pelvic inflammation and suppuration in the female 526 

Benign and new growths of the female pelvis C27 

Polypi - 527 

Cystic tumors of the ovaries and broad ligaments 527 

Dermoid cysts of the ovary and ligaments 528 

Ovarian fibromata 528 

Uterine fibroid tumors '. ■ 528 

Malignant new growths; sarcomata and carcinomata 529 

Cancer of the cervix uteri 529 

Cancer of the body of the uterus 530 

Malignant tumors of the ovary 530 

Abortion; miscarriage 530 

Puerperal sepsis 531 



XViii CONTENTS 



CHAPTER XX 

OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM 

PAGE 

Diseases of bone 533 

Remarks on the pathology of inflammation in bone 533 

Acute bone inflammation 535 

Osteoperiostitis 535 

Acute infectious osteomyelitis 535 

Acute epiphysitis 536 

Pyacmic abscess of bone 536 

Chronic inflammation of bone 536 

Tuberculosis of bone 536 

Syphilis of bone 538 

Actinomycosis of bone 539 

Benign tumors of bone 539 

Malignant tumors of bone 540 

Osteomalacia (moUities ossium) 542 



CHAPTER XXI 
OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM — Continued 

Diseases of joints and bursae 644 

General remarks 544 

Clinical varieties of joint lesions 545 

Sprains 645 

Synovitis 646 

Arthritis 646 

Joint affections in bleeders; scurv^y and gout . . 647 

Acute articular rheumatism; rheumatic fever 647 

Manifestations of rheumatism in children 660 

Arthritis deformans 551 

Chronic rheumatic arthritis; chronic rheumatism 556 

Syphilitic arthritis 556 

Tuberculosis of the joints 557 

Loose bodies in joints 558 

Displacement of the semilunar cartilages 669 

. Neoplasms of joints 669 

Neuroses of joints 669 

Neuropathic arthritis 569 

Bursitis 560 

CHAPTER XXII 

OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM — Continued 

Diseases of muscles, tendons, and fasciae 661 

The muscles 561 

The muscular dystrophies 665 

The tendons 666 

The fasciae 668 



CONTENTS xix 

CHAPTER XXIII 

OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM — Continued 

FAOB 

Orthopaedic memoranda 569 

Wolff's law 569 

Pott's disease 569 

Torticollis 575 

Lateral curv'ature of the spine 576 

Rigid spine; spondylitis deformans (spondylose rhizom^lique) 579 

Hip disease 580 

Congenital dislocation of the hip 583 

Coxa vara 586 

Knee disease 587 

Achillodjrnia 589 

Anterior metatarsalgia 589 

Anterior poliomyelitis and paralytic club foot 591 

Flat foot 592 

Flat foot of children 595 

CHAPTER XXIV 

OSSEOUS, MUSCULAR, AND ARTICULAR SYSTEM — Concluded 

Massage, Swedish movements, vibratory stimulation, and hot air treatment . . 596 

Remarks on massage and Swedish movements 596 

Massage treatment of the digestive and pelvic organs 597 

Massage as an aid to the circulation of blood and lymph 597 

Treatment of stiff joints by massage and movements 598 

Treatment of sprains by early massage 598 

Mechanical vibration; vibratory massage; vibratory stimulation .... 600 

Dry hot air treatment 600 

CHAPTER XXV 

INFECTIOUS AND CONTAGIOUS FEVERS 

Introductory remarks 602 

Remarks on prophylaxis and disinfection 603 

Infectious and contagious fevers 609 

Malarial or intermittent fevers. 609 

Enteric fevers (typhoid and para-typhoid fevers) 616 

Treatment of complications and sequelae 624 

Influenza 625 

Yellow fever , 627 

Typhus fever 628 

Dengue 630 

Relapsing fever 631 

Cholera asiatica 632 

Variola 634 

Vaccinia, or cowpox; vaccination 640 

Bubonic plague; pest; black death 641 



XX CONTENTS 



CHAPTER XXVI 

DISEASES DUE TO FAULTY METABOLISM, TO FAULTY INTERNAL SECRETIONS, AND TO 
DERANGEMENTS OF THE DUCTLESS GLANDS 

PAGE 

Gout 643 

Glycosuria and diabetes meJlitus 651 

Obesity 658 

Scurvy, scorbutus, in adults 661 

Derangements of the ductless glands 664 

The thyreoid gland 664 

Myxcedema 664 

Hypothyreoidism 666 

Cretinism (congenital myxcedema; myxcedema of childhood) 666 

Basedow's disease (Parry's disease; Grave's disease; exophthalmic goitre) . 667 

The suprarenal gland 670 

Addison's disease (morbus Addisonii; bronzed disease) 670 

Diseases of the pituitary body 672 

Acromegaly .*.... 672 

The spleen 673 

General remarks 673 

Splenic anaemia 674 

CHAPTER XXVII 

THE NERVOUS SYSTEM; NEUROLOGICAL MEMORANDA • 

Remarks on the clinical pathology of the nervous system 675 

Motor phenomena 676 

Paralysis and paresis 676 

Sensory, secretory, and special sense phenomena 679 

Reflexes 679 

Trophic disturbances 681 

Remarks on aphasia 681 

Psychical conditions 681 

Insomnia (sleeplessness) 681 

Familiar points in cerebral localization 681 

Remarks on the application of electricity 681 

Action of the electric current upon living tissues 682 

Electricity in practice 682 

Examination scheme in nervous derangements 683 

The nerve clinic . 685 

Neuralgias; painful tics; headache; migraine 685 

Forms of neuralgia 685 

General principles of treatment of neuralgias 687 

Headache 688 

Migraine; hemicrania (sick headache) 689 

Disturbances with predominating undue motion of central, peripheral, or unknown 

origin; (tics) 691 

Occupation neuroses 691 

Tetany; pseudotetanus 693 

Paralysis agitans (shaking palsy; Parkinson's disease) 693 

Obstinate hiccough 694 



CONTENTS xxi 

PAGE 

Disturbances with loss of power of motion predominating (palsies, acute and chronic) 695 

Cerebral apoplexy (haemorrhage, embolism, and thrombosis) 695 

Bulbar paralysis (glossolabiolaryngeal paralysis) 697 

Ophthalmoplegia 697 

Spinal apoplexy 698 

Anterior poliomyelitis 698 

Spinal progressive muscular atrophy; wasting palsy (Aran-Duchenne type) . 698 

Progressive hereditary muscular atrophy, perineal (Charcot-Marie type) . . 699 

Amytrophic lateral sclerosis 700 

Lateral sclerosis 700 

Locomotor ataxia (tabes dorsalis; posterior spinal sclerosis) 701 

Hereditary ataxia (Friedreich's ataxia) 704 

Ataxia paraplegia (combined sclerosis) 704 

Myelitis 704 

Acute ascending paralysis (Landry's paralysis) 707 

Syringomyelia 707 

Cerebrospinal sclerosis (multiple or disseminated sclerosis) 707 

Diver's paralysis (caisson disease) 708 

Cranial nerve palsies 708 

Neuritis 711 

Multiple neuritis . 712 

Disturbances with loss of consciousness predominating 714 

Vertigo 714 

Delirium 715 

Coma 718 

Eclampsia; convulsions 718 

Puerperal eclampsia 718 

Epilepsy 721 

Sleeping sickness; negro lethargy; trypanosomiasis 725 

Derangements with psychical alterations predominating 725 

Neurasthenia 726 

The traumatic neuroses; traumatic hysteria 730 

Insomnia 731 

Hypnotism, or suggestion; trance 732 

Classification of mental disturbances 733 

Vasomotor and trophic disturbances 734 

Raynaud's disease 734 

Erythromelalgia 735 

Meningitis in adults 737 

General diagnostic and therapeutic remarks . . . . • 737 

Acute and chronic leptomeningitis in adults 739 

Acute cerebral leptomeningitis 739 

Acute spinal leptomeningitis 741 

Chronic rpeningitis (chronic leptomeningitis) . . 741 

Chronic leptomeningitis spinalis 742 

Cerebrospinal meningitis in adults 743 

Tuberculous meningitis in adults 747 

Acute external pachymeningitis 747 

Chronic internal pachymeningitis 748 

Spinal pachymeningitis 748 

Pachymeningitis externa spinalis 748 

Pachymeningitis interna hsemorrhagica spinalis 748 

Pachymeningitis interna hypertrophica spinalis 748 



xxii CONTENTS 

PAGE 

Syphilis of the nervous system 749 

Syphilitic endarteritis 749 

Syphilitic toxaemia 749 

Syphilitic exudations into the meninges 749 

Other syphilitic conditions 750 

Miscellaneous lesions in the brain and spinal cord in which localization and surgical aid 

is possible 751 

Injuries to the brain 751 

Contusion and laceration 751 

Meningeal haemorrhage 752 

Haemorrhage between the dura mater and the skull 752 

Haemorrhage between the dura mater and the pia mater 752 

Concussion of the brain 753 

Compression of the brain 754 

Tumors of the brain 757 

Thrombosis of the venous sinuses 760 

Abscess of the brain (suppurative encephalitis) 761 

Parasites of the brain 762 

Injuries of the spinal cord 763 

Haemorrhage into the spinal membranes 763 

Remarks on the sympathetic nervous system 765 

Anatomical anomalies 765 

Abnormities of the brain 765 

Malformations of the spinal cord 766 

Spina bifida (rhachischisis posterior) 766 

Other malformations 767 

Stigmata of degeneration (Peterson) 767 

Remarks on idiocy and amaurotic family idiocy 767 

Amaurotic family idiocy 768 

CHAPTER XXVIII 

DERMATOLOGICAL MEMORANDA 

Introductory remarks 769 

Diseases of the glandular apparatus 770 

Sweat glands 771 

Sebaceous glands 771 

Seborrhoea (acne sebacea; tinea furfuracea; dandruff) 772 

Anomalies of pigmentation 772 

Chloasma; vitiligo; lentigo; albinismus 772 

Inflammations 772 

Dermatitis 773 

Ecthyma 776 

Eczema (tetter; salt rheum; scall) 776 

Erythema 777 

Herpes 777 

Impetigo 778 

Ichthyosis (fish skin disease) 778 

Lichen 779 

Miliaria (sudamina; prickly heat) strophulus 779 

Pemphigus (water blisters) 779 

Pityriasis 780 



k 



CONTENTS xxiii 

PAGE 

Prurigo 780 

Psoriasis (lepra alphos) 780 

Sclerema (neonatorum) 781 

Scleroderma (hide-bound disease) 781 

Urticaria (hives; nettle rash) 781 

Xeroderma (xerosis) 782 

Parasitic skin diseases 782 

Animal 782 

Vegetable 782 

Neoplasms and new growths 789 

Benign 789 

Malignant neoplasms 793 

Dermatoneuroses 795 

Sensory dermatoneuroses 795 

Motor dermatoneuroses 796 

Trophic dermatoneuroses 796 

Chronic trophoneurotic erythema 796 

Vascular dermatoneuroses 796 

Mai perforans (perforating ulcer of the foot) 798 

Diseases of the appendages 797 

The hair .797 

Atrophy of the hair; alopecia (baldness) 797 

Hypertrophy of the hair 797 

The nails 797 

Formulary 798 

CHAPTER XXIX 

OTIC MEMORANDA 

General remarks 806 

Minor local ailments in or about the ear . . ' 807 

Otitis media, acute and chronic 808 

Mastoid disease 809 

Sense of hearing 809 

Diagnostic value of fluid discharges from the ear in head injuries 811 

Formulary 811 

CHAPTER XXX 

OPHTHALMIC MEMORANDA 

General remarks 812 

Sense of sight 812 

The pupils 814 

The ophthalmoscope 815 

Injuries of the eye and foreign bodies 815 

Diseases of the eyelids 816 

Diseases of the lacrymal apparatus . . . • 817 

Conjunctivitis and trachoma 817 

Keratitis 818 

Diseases of the sclera, ciliary body, and chorioid 819 

Iritis 819 

Glaucoma 819 



xxiv CONTENTS 

PAGE 

Disease of the retina 820 

Detachment of the retina 820 

Diseases of the optic nerve 822 

Cataract and opacities 821 

Squint, strabismus 821 

Eyesight and eye strain 821 

Eye formulary 822 

CHAPTER XXXI 

ANAESTHESIA, INTOXICATIONS, MISCELLANEOUS AILMENTS, KEEPING CASE RECORDS AND 

ACCOUNTS 

Anaesthesia 823 

Ilemarks on local and general anaesthesia 823 

Intoxicants 825 

Poisons and antidotes 825 

Insect and snake bites 828 

Drug habits 830 

Alcoholism 831 

Miscellaneous ailments 831 

Seasickness (mal de mer) 831 

Mountain sickness 832 

Hydrophobia (rabies; lyssa) 832 

Septic wounds and traumatic tetanus 833 

The keeping of records of cases under treatment and their accounts in private practice 833 



LIST OF ILLUSTRATIONS 



FIGURE PAGE 

1. Einhom Saccharometer 21 

2. Ureometer 23 

3. Scolex and Segments of Taenia Saginata 29 

4. Taenia Solium 29 

5. Taenia Echinococcus, magnified twenty diameters 30 

6. Contents of an Echinococcus Cyst showing Scolices, Booklets and Cholesterin 

Crystals 30 

7. Ascaris Lumbricoides (romidworms) 30 

8. Oxyuris (pinworms) 30 

9. Haemoglobinometer 42 

10. Thoma-Zeiss Pipettes ^ 43 

11. Counting Slide (plan) 43 

12. Blood Counting Slide (elevation) 45 

13. Blood Counting Diaphragm. Actual Size 45 

14. Counting Blood Cells 46 

15. Making a Blood Smear on a Slide 50 

16. Gavage (feeding by means of the Stomach Tube) 60 

17. Soft Rubber Stomach Tube 61 

18. Stomach Washing in Adults . 61 

19. Stomach Washing in Infants by Means of a Fountain Syringe at an Elevation 

of Four Feet .62 

20. T Cannula for Irrigation 62 

21. Bowel Irrigation in Infants and Children .63 

22. Kemp's Rectal Irrigator (double current catheter) 64 

23. Hot Pack 66 

24. Enteroclysis 69 

25. Hypodermoclysis 70 

26. Apparatus for Venous Infusion 73 

27. Atomizer for Albolene 77 

28. Technique of Venesection 79 

29. Dry Cupping 81 

30. Nasopharyngeal Toilet 81 

31. Blunt Nasal Irrigation Syringe 81 

32. Infection and Sloughing of the Skin from Unclean Hypodermatic Injections . 84 

33. Bed Grapple for the Comfort of Patients 84 

34. 35. Feely Invalid Bed 85 

36. How to Hold the Baby; Faulty Way, Correct Way 90 

37. Incubator for Premature Children 91 

38. Encephalocele. Vault of Cranium Absent. Age One Year . . , ' . . 98 

39. Encephalocele at Three Years 99 

40. Achondroplasia 100 

41. Enlarged Thymus 101 

42. Spina Bifida 102 



xxvi LIST OF ILLUSTRATIONS 

FIOURE PAGE 

43. Thoraco Abdomino Pagus ,103 

44. Thoraco Abdomino Pagus (skiagram) 104 

45. Bronchocele 105 

46. Marked Curve of Little Finger of Mongolian Idiot 106 

47. Arnold Sterilizer and Pasteurizer 114 

48. Lactometer 118 

49. Cream Testing Outfit 118 

50. Chapin Dipper 121 

51. Seibert's Aluminum Milk Filter, with Cotton Disk 121 

52. Rhacitic Fiat Foot in Child of Nine Months 142 

53. Comfortable Position for Children with Rhacitic Weak Back .... 143 

54. Carrying-Frame for Feeble Rhachitic Children 145 

55. Rhachitic Deformity 145 

56. Rhachitis. Genu Varum Before Operation 146 

57. Rhachitis. Genu Varum After Operation 146 

58. Rhachitis. Genu Valgum Before Operation 146 

59. Rhachitis. Genu Valgum After Operation 146 

60. Infantile Scurvy and Marasmus 147 

61. Tuberculous Peritonitis with Ascites 148 

62. Tuberculous Peritonitis of Two Years' Standing . , 149 

63. Tuberculous Peritonitis and Hernia 150 

64. Tuberculous Peritonitis with Cystic Accumulation of Fluid (operation) . . 151 

65. Temperature Curve in a case of Septic Bronchopneumonia in Child, Ending in 

Recovery 154 

66. Fever Curve in Tuberculosis of Lung and Unresolved Pneumonia Compared in 

Cases of Empyema 167 

67. Household Reflector 172 

68. Intubation Tube in Situ (skiagram) 180 

69. Intubation Tube in Situ (skiagram) 182 

70. O'Dwyer's Instrument Set 183 

71. O'Dwyer's Intubation Instruments 184 

72-75. Technique of Intubation 185 

76. Intubation of the Larynx 186 

77. Intubation Statistics of Budapest Stephanie Children's Hospital .... 187 

78. Larynx of a Child Two and a Half Years Old showing Ulceration , . . 188 

79. Built Up Head for Granulations 189 

80. Author's Automatic Tracheal Retractor 189 

81. Cleansing Tracheotomy Wound with Tube in Situ 190 

82. McKenzie's Tonsillotome 193 

83. Tiemann-Fahnenstock Tonsillotome 194 

84. Tonsil Knife 194 

85. Beckmann's Curette for Adenoids 195 

86. Post Nasal Fenestrated Forceps for Adenoids 195 

87. Adenoids Before Operation 195 

88. Adenoids After Operation 195 

89. Adenoids Before Operation 196 

90. Adenoids After Operation 196 

91. Temperature Curve in Measles 199 

92. Pseudohypertrophic Muscular Paralysis 217 

93. Pseudohypertrophic Muscular Paralysis 218 

94. Cerebrospinal Meningitis 221 

95. Meningitis 222 

96. Spinal Puncture. Forward Bicycle Position 223 



LIST OF ILLUSTRATIONS Xxvii 

FIGURE PAGE 

97. Ice Water Coil in Meningitis ... 224 

98. Hydrocephalus ^. . . 225 

99. One Year Old Child *. . . 227 

100. Same Child. Pronounced Cretin at Two Years 227 

101. Same Child. Four Weeks After Treatment with Thyreoid 227 

102. Same Child. Ten Weeks After Treatment with Thyreoid 227 

103. Showing Sixth Year Molar Teeth 251 

104. 105. Showing Set of Teeth at Six Years 252, 253 

106. Showing Set of Teeth at Eleven Years 254 

107. Introducing (Esophageal Bougie 260 

108. Illumination of the Stomach by Means of Fluorescein and the Electric Light . 267 

109. Enteroclysis 284 

110. Tuberculous Ulcer of the Ileum 291 

111. Represents a Properly Applied Truss for the Retension of Double Inguinal 

Hernia 298 

112. Skein of Worsted Truss 298 

1 13. Abdominal Support, Plaster and Webbing 301 

114. Cancer of the Liver 319 

115. Dulness in Hypertrophy of the Left Ventricle 337 

116. Showing the Dulness due to Dilatation and Hypertrophy of Both Ventricles . 338 

117. Rupture of the Heart . . 339 

118. The Triangular Area of Dulness due to a Large Pericardial Effusion, Shown by 

the Outer Solid Line 342 

1 19. Aortic Aneurysm • . . . . 362 

120. Unique Case of Chronic Lymph Stasis 364 

121. SplenomeduUary Leucaemia 379 

122. Longitudinal Scarification for ffidema . 390 

123. Tapping the Abdomen under Local Ana?sthesia 392 

124. Permanent Drainage for Ascites 393 

125. Exploratory Puncture of the Chest under Ethyl Chloride Local Ana?sthesia . 394 

126. Aspirator 395 

127. Heat Vacuum Aspirator 396 

128. Examination of the Anterior Nose by Means of a Nasal Speculum and Reflected 

Light 412 

129. Laryngoscopy and Posterior Rhinoscopy 413 

130. Bivalve Nasal Speculum 414 

131. Spray Tubes 415 

132. Albolene Atomizer 416 

133. Snaring Posterior Nasal Hypertrophies 417 

134. Fibroma of the Vocal Cord 420 

135. Jarvis' Snare, Straight or Curved 421 

136. Congenital Papilloma of Larynx 421 

137. Epithelioma of the Larynx . 421 

138. Sarcoma of the Epiglottis 422 

139. Peritonsillar Abscess 425 

140. Effect of One Dose of Quinia in a Case of Malarial Bronchopneumonia . . . 435 

141. Diphtheritic Bronchial and Tracheal Cast 436 

142. Fibronous Cast of the Bronchi 443 

143. Skiagram of Normal Thorax 448 

144. Skiagram. Right Lung Cavernous, Left Lung Consolidated .... 449 

145. Sanitary Pocket Cuspidor 451 

146. Paper Cuspidor 451 

147. Window Tent for Open Air Treatment at Home 452 



xxviii LIST OF ILLUSTRATIONS 

FIGURE PAGE 

148. Cut of Window Tent showing Ventilation . . . . . .453 

149. Out Door Rest Cure .454 

150. Out Door "feest Cure 455 

151. The Tucker Tent 456 

152. Lung Gymnastics 463 

153. Sources of Pyuria 474 

154. Sacculated Prolapse of the Right Ureter 485 

155. For Bladder Irrigation 488 

156. Urethral Hand Syringe 504 

157. Urethroscope 504 

158. Stocking and Strap Leg Holder in Dorsal Posture 509 

159. Bimanual Palpation of Female Pelvic Organs (No. 1) 510 

160. Bimanual Palpation of Female Pelvic Organs (No. 2) 511 

161. Supporting Belt 522 

162. Sub-Urethral Abscess 522 

163. Prolapse of the Ovary . 523 

164. Abdominal Support of Plaster and Webbing . . . . . . . . 524 

165. Pelvic Hsematoma 525 

166. Pelvic Abscess 526 

167. Tuberculosis of Os Calcis 537 

168. Tuberculous Focus in Tibia, Healed. Skiagram 538 

169. Tuberculous Knee Disease 538 

170. Tuberculous Disease of Elbow 539 

171. Osteomalacia Deformity 542 

172. Strapping the Knee 545 

173. Arthritis Deformans of Spine 552 

174. Hip Disease Showing Flexion Deformity 557 

175. Charcot Knee Joint (Tabes Dorsalis) 560 

176. Trichina Spiralis Encysted in Muscle 564 

177. Contracture of Palmar Fascia 568 

178. Bradford Carrying Frame for Pott's Disease 570 

179. Bradford Frame— Child Able to Walk 570 

ISp. Pott's Disease Plaster Jacket and Headspring 571 

181. High Cervical Pott's Disease, showing Characteristic Posture of Child . . 572 

182. Spinal Tuberculous Abscess 573 

183. Cervical Pott's Disease, showing Characteristic Broadening of the Neck . . 574 

184. Pott's Disease, showing Kyphos and Abscess 575 

185. Applying Plaster of Paris Jacket 576 

186. Torticollis showing Facial Asymmetry 577 

187. Scoliosis 578 

188. Exercise for Scoliosis 579 

189. Hip Splint 580 

190. Bed Extension in Hip Disease 581 

191. Lorenz Spica 583 

192. Double Spica after Reduction of Double Congenital Dislocation of Hip . . 584 

193. Lorenz Hip Redresseur 585 

194. Coxa Vara 586 

195. Bow Legs and Congenital Deformity of Upper Extremity 588 

196. Knock Knee " . 589 

197. Club Foot 590 

198. Talipes Equinus from Infantile Paralysis 591 

199. Talipes Calcaneus 592 

200. Krukenberg's Pendulum Apparatus for Treatment of Flat Foot .... 593 



LIST OF ILLUSTRATIONS Xxix 

FIGURE PAGE 

201. Flat Foot 594 

202. Dry Hot Air Treatment 598 

203. Application of the Chattanooga Vibrator 599 

204. Dry Hot Air Treatment for Arm or Leg 600 

205. Formaldehyde Sterilizer 607 

206. Tertian Malaria . 613 

207. Typhoid Fever in Berlin Before and After Sand Filtration of Drinking Water . 617 

208. Pulse, Respiration and Fever Curve in Uncomplicated Typhoid Fever . . 620 

209. The Value of Vaccination 635 

210. Spastic Paraplegia 677 

211. Muscular Dystrophy 678 

212. Muscular Dystrophy 679 

213. Symmetrical Gangrene 735 

214. Hemiatrophia Facialis Progressiva 736 

215. Dressing for Ulcer of the Leg . . 773 

216. Gauze Mask and Splints to Prevent Scratching in Eczema 776 

217. Contagious Impetigo 778 

218. Pediculus Pubis 782 

219. Male and Female of Sarcoptes Scabiei 783 

220. Papulo-Pustular Syphilide sent to Municipal Hospital as a Case of Smallpox . 787 

221. Eustachian Catheters 806 

222. Examination of the Ear 807 

223. Double Current Irrigator for the Ear 810 

224. Opthalmoscopic Examination 813 

225. Emergency Poisoning Case 830 

226. Case Record 834 

227. Case Record 835 

228. Day-Book and Ledger 836 



INTRODUCTION 



To be able to recognize the clinical form of disease and to aid nature in 
its reparative endeavors is the aim of the physician. The time was, and it is 
within the memory of many of us, when the family practitioner was the trusted 
family counselor in all matters concerning health and sickness. Before the 
advent of antisepsis and specialism and the acceptance of the germ theory 
in medicine, every mature and successful practitioncjr was the authority for 
his clientele. Disease was looked upon as a visitation of Providence, the 
belief in the virtues of drugs and medicines was absolute, and surgery was 
brutal and simple. 

At the opening of the twentieth century no profession stands in a more 
advanced position than that of medicine. General and local angesthesia, 
asepsis and antisepsis, chemical and bacteriological research, with subsequent 
therapeutics on entirely new lines (serum and organotherapy) have opened 
up vast diagnostic and therapeutic possibilities. 

Anaesthesia, antiseptic wound treatment, and antitoxines have reduced 
the sum total of pain and misery. The introduction of cocaine has been 
followed by a rapid development of the nose and throat specialty and has 
made the work of the time-honored ophthalmologist easier. Bacteriology 
and chemical research have given to all departments in the practice of medicine 
a marvelous diagnostic precision, complexity of terms, and an avalanche of 
literature which have completely swamped the all-round medical man, and 
make it difhcult for the special worker in medicine to keep abreast of the 
times and events. 

Owing to the great strides which practical and theoretical medicine have 
made in the past twenty-five years, the position of the general practitioner 
to-day is a peculiar one. He has found it impossible to keep abreast with the * 
rapid progress in piedicine; any young specialist feels himself his superior 
in his particular line, and, in our large cities, among the wealthy class, the 
general practitioner finds himself little more than " master of the ceremonies " 
— the diagnosis and treatment are furnished by the various consultants and 
the patient is handled by the trained nurse. 

These matters have been discussed at various times and from divers stand- 
points, but no definite and precise advice has been formulated for the guidance 
of the student, or prospective student, or young practitioner, who in his en- 
thusiasm for the study of medicine fails to take into consideration the great 
difficulties which beset him in the practice of his chosen profession. 

It may not be out of place (before analyzing the future prospects of the 
family practitioner) to answer the question " To what extent shall we en- 
courage young men and women to take up the practice of medicine as a liveli- 
2 1 



2 INTRODUCTION 

hood? " To judge from the large number of medical men who are yearly let 
loose upon the public, it would appear that medicine is looked upon as a very 
promising field for reward, in fame and riches. Such an assumption is, how- 
ever, not warranted by existing conditions. The law of supply and demand 
is inexorable, and we may have an overstocked profession just as we may 
have an overstocked market in flour or cheese. 

Owing to the fact that many have entered the medical profession from 
impulse or fancy, the production of medical practitioners has been far ahead 
of the demand, and although an increase in population and the dropping out 
of the old members of our profession will make room for newcomers, there 
will certainly not be room for all who are clamoring for admission to its ranks. 
To my mind no one should attempt to enter upon such a career without a good 
physical constitution, a sound mind, a tactful disposition, and a thorough 
appreciation of the situation which confronts him, a full understanding of 
the difficulties to be overcome, and the hard work and drudgery to be endured 
by the general practitioner, be he successful or not. Competition is a stern 
master; it elevates and degrades, and the position of the medical man who 
in the battle of life has lowered his standard of honesty and loses his self- 
respect by reason of practices unworthy of a gentleman and a true physician 
is a deplorable one, be the money reward small or great. 

Is there a place in society for the family practitioner, and if so, under what 
precise conditions will he he in demand f 

I firmly believe that the family practitioner is not doomed to become 
extinct and that in due time the people will again elevate him to the position 
of trusted family counselor, and this opinion I hold for two reasons principally. 

In the first place, many intelligent people who are fortunate enough to 
have the services of a thoroughly good family practitioner have refused to 
give him up and have upheld the dignity of his position on every occasion 
where the counsel and services of a specialist were in demand ; and in the second 
place the public has already experienced the many and serious drawbacks of 
an indiscriminate consultation with immature specialists whose advice, if 
followed, has in many instances been bought more dearly than by dollars 
and cents. 

Much of the specialist work of to-day is worthy of the highest praise; 
on the other hand, a large percentage of operative work is ill advised, super- 
fluous, and harmful, and as soon as the more intelligent people of the com- 
munity realize that such is the case they will again turn for advice to the 
intelligent family practitioner; they will admit him again to the inner family 
council and trust to him to shield them from the meddlesome treatment of 
our times and deliver them into conservative and safe hands. And if the 
future family practitioner is to regain lost ground, again aspire to reach that 
plane in the practice of general medicine which is properly his, and again 
enjoy the full confidence of his clientele, it must be through his own individual 
efforts by educating himself to become a diagnostician. In view of the com- 
plex characters which are features of some of the special examinations, this 
may seem a herculean task, but I am convinced that all medical men who 
are fitted by nature and proper education for their work, will in reasonable 
time become competent diagnosticians and will be capable of formulating 
precise indications for treatment, provided ample opportunity for laboratory 



INTRODUCTION 3 

and bedside instruction be offered and sought, and provided that no time be 
wasted experimenting with thousands of old and new and useless drugs in 
the endeavor to adapt a complex, cumbersome, and largely superfluous materia 
medica to the various symptoms of acute and chronic illness. 

The general practitioner must be: 1. Master of physical diagnosis. 2. He 
must have some laboratory training, particularly if he practises far away 
from laboratory facilities. 3. He must be able to make a local or regional 
examination, employing such of the methods of specialists which have become 
general property. 4. He must have a good knowledge of hygiene and dietet- 
ics. 5. He must be able to practise minor surgery and be able to perform 
emergency operations. 6. Whenever feasible, obstetrical cases should not 
be handled by the general practitioner. 

A thorough training in physical diagnosis is the basis of a successful 
medical career. Once properly learned, it is never forgotten, and as long as 
we are in active practice, auscultation and percussion are and should be our 
daily routine work. 

The various orifices of the body are accessible to the finger (touch), or, 
by means of simple instruments or specula, they are accessible to sight, 
and it is certainly lack of energy and self-confidence if the general prac- 
titioner fails to make use of ordinary local examination methods which 
may have been first introduced by the speciaHst, but have long ago become 
public property. 

The intelligent layman will understand that the family doctor may not 
be prepared for a thorough ophthalmoscopic or cystoscopic examination, 
but why he should require other men to look into the mouth, nose, throat, and 
other regions, or to siphon out the stomach contents, and send fluids and 
blood to the laboratory for examination, is something he will not understand, 
and if he finds from experience that for local examinations a double fee will 
be entailed — that of the family doctor and that of the specialist — he will 
soon come to the conclusion that he may as well go to headquarters at once 
without consulting the family doctor at all. Things are very different when 
a patient is sent to a specialist for a corroboration of diagnosis or opinion. 
Two heads are sometimes better than one, and in obscure or serious cases a 
medical man will not suffer in the estimation of his patient if he requests the 
counsel or services of a professional colleague. 

Under all circumstances the general practitioner should direct his energies 
to making a diagnosis himself and formulating precise indications for treatment. 
His patients will understand that he can not be a Jack of all trades and perform 
everything, but they will expect him to make a diagnosis and suggest proper 
treatment. 

The attendance upon obstetrical cases has always been one of the duties 
of the general practitioner, and medical men have felt that from the first 
successful confinement case in a family dates the firm position which they 
may have eventually held as the family attendant. 

Now, there are two reasons why the general practitioner should not as a 
rule attend obstetrical cases. The minor reason is that such cases usually in- 
volve night work, and a physician who works from 8 a. m. to 10 p. m. should go 
to bed and sleep unless called out by some serious emergency case. Life is 
short and we are entitled to some creature comforts. The important point is, 



4 INTRODUCTION 

that a general practitioner is at all times in contact with contagious or com- 
municable disease and may, in fact does, infect parturient women. The more 
intelligent women in city practice will readily accept the services of an ob- 
stetrician other than the family doctor, if it is made clear to them that they 
escape the dangers of childbed fever and its sequelae by such management. 
Among the poor people a well trained midwife who knows how to disinfect 
her hands is a safer attendant upon a woman in labor than the general prac- 
titioner who comes from a case of scarlet fever or erysipelas and is for some 
reason or other always in a great hurry and prone to help things along by 
the aid of his forceps. 

This field properly belongs to that class of practitioners whose chief work 
is obstetrics, to which almost all their time must be allotted to do full justice 
to their cases. 

How far such an arrangement might be possible in country practice remains 
to be seen. 

This hurry and bustle in the life of the general practitioner is all wrong 
and for the safety of our patients is bad. 

The general practitioner must fight against and not encourage the hys- 
terical activity of our times. He should give time and thought to his cases, 
and his fee should be in accordance with the time spent and with the circum- 
stances of the patient. 

As things stand to-day the general practitioner is not sufficiently paid for 
his services and is compelled to see more patients than is proper or safe. An 
overworked brain is responsible for such sins of omission as are occasionally 
laid at the door of medical practitioners. Sins of commission are not frequent. 
The remedy lies more with the people than with the profession, A " fussy " 
doctor who turns a household upside down on every occasion of illness, severe 
or trivial, is a very popular person among a certain and large class of people 
who delight in boring their friends and acquaintances with the harrowing 
details of their latest sickness and miraculous escape from sure death. Physi- 
cians are needlessly called out at night; they are not sufficiently paid, and a 
proper understanding of the situation by our patients would do more to set 
the pace of the doctor than anything else. 

To counterbalance the deficit which must result from the loss of fees for 
obstetrical work, the general practitioner will have more time to devote to 
himself and his family, and more time and ambition to practise minor surgery. 
Minor surgery, in my opinion, belongs to the general practitioner. The 
practice of minor surgery is easy and it is more impressive to the laity than 
the writing of a prescription for a lot of useless and superfluous drugs. A 
general practitioner without surgical training and tendencies is handicapped 
from the very start. As he is brought into early contact with cases requiring 
surgical aid, his timely recognition of the case and use of the knife will be of 
the greatest importance and value in cases which, if seen at a late stage by 
the special surgeon, frequently necessitate extensive surgical interference. 
Local and general anaesthesia have robbed surgery of much of its brutality. 
The knife in conservative hands aids nature and frequently gives prompt 
relief from pain and dangerous symptoms, and it is for this reason that surgeons 
get large fees for small operations and the timid general practitioner gets little 
or nothing. Disease does not run its course as purely medical or purely 



INTRODUCTION 5 

surgical. Such a division does not exist in nature. Rheumatism, typhoid 
fever, tuberculosis, pneumonia, diabetes, and a host of other so called medical 
diseases often present complicating features requiring surgical knowledge and 
interference, which the general practitioner will detect or remedy in good time 
if he has the necessary and proper education, and vice versa, purely surgical 
cases frequently develop non-surgical complications. Thus the Simon-pure 
prescription- writer has no future in the modern practice of medicine, and the 
medical man or woman who does not care to handle the knife should drift 
into a mild, bloodless specialty. Just how far the general practitioner may go 
in the practice of surgical handicraft will depend upon the taste and fancy 
of the individual. Every man will know his limitation and will do well to call 
in a special surgeon in cases requiring strict asepsis and in cases of a graver 
nature. 

For small towns or in country practice I should advocate that neighboring 
general practitioners combine for the purpose of assisting one another in cases 
of minor surgery, emergency operations and the like, and trained nurses 
should be encouraged to locate in small towns for the purpose of aiding the 
medical men by making the usual preparations for operation and by nursing 
such cases after operation. I would suggest that a nurse who has been taught 
massage, diet kitchen work, and obstetrical nursing, in addition to ordinary 
nursing, should be encouraged to locate as above, and I feel that such a one 
would often get into a greater sphere of usefulness than by remaining in the 
large cities with their competitive overcrowding. I regard it as essential that 
the rural community should be educated as to the necessity and desirability 
of such services. 

Another point of great interest to the general practitioner is the labora- 
tory work (clinical microscopy and chemical research), without which no one 
can practise medicine with comfort to himself and his patients, because it is 
necessary for correct diagnosis. The microscope shows us a series of specific 
microorganisms, also changes in tissues and blood; and pathological changes 
in digestive and eliminative organs may sometimes be inferred from a clinical 
examination of various secretions. 

But it must not for a moment be inferred that the general practitioner 
must do all this work himself, for this would be an impossibility. Fine labora- 
tory work is a speciality in itself, and all that is required in this line of the prac- 
tical physician of to-day are the very gross urinary, blood, and sputum tests, 
and stomach contents tests which can be made in short order. Everything 
else should go to the laboratory to be examined by experts, and patients should 
be told that a fee for laboratory work will be asked. In large cities, laboratories 
have been established by private enterprise or in connection with the medical 
schools and hospitals, and for the general practitioner it is no more necessary 
to have a private laboratory than it is to have his own drug shop or his own 
livery-stable. As a matter of expediency and convenience all ordinary simple 
examinations can be made as heretofore in the office. 

We can not with good grace dismiss the general practitioner and his re- 
quirements without speaking in plain language in condemnation of the drug- 
ging habit of which he is still guilty to a remarkable degree. Cabalistic 
prescriptions are still as thick as flies in summer, and the majority of our 
patients pay willingly and handsomely for our wisdom transmitted to them 



6 INTRODUCTION 

in the shape of nauseating mixtures from the time-honored shelves of the 
apothecary shop. 

I know from personal observation that our cousins across the water do 
not prescribe or swallow one quarter as much medicine as we do in our country. 
With but few exceptions the entire vegetable and mineral kingdoms have 
given us little of specific value, but still up to the present day the bulk of 
our books on materia medica is made up of descriptions of many valueless 
drugs and preparations. 

Is it not to be deplored that valuable time should be wasted in our student 
days by cramming into our heads a lot of therapeutic ballast, and is it not 
true that such teaching is to a large degree responsible for the desire on the 
part of the many practitioners to prescribe frequently and without good cause 
an unnecessary quantity of useless drugs ? 

Every few weeks new drugs and combinations of medicaments are forced 
upon physicians with the claim that they are specifics in the treatment of 
disease, and the physician in his anxiety to alleviate his patients' sufferings, 
because the simpler and more reliable have failed him, is gulled into trying 
the newly extolled remedy, only to find that it is still less efficacious than the 
old one. 

The common sense practitioner knows by experience that the constant fre- 
quent prescribing of innumerable drugs only ends in detriment to his patients. 
A working knowledge of hygiene and dietetics, climate, hydro- and mechano- 
therapeutics, simple medication and few drugs are the successful agents in 
internal medicine, and the sooner the physician will condense his pharmacopceia 
and materia medica to a vest pocket edition the sooner will his efforts meet with 
success in the practice of his profession, and the sooner will Christian Science 
delusions disappear from the surface. 

There is still one point which must be discussed and that is : How shall the 
general practitioner keep up with the progress of our art? 

Here again the city colleague has an advantage over the country prac- 
titioner, inasmuch as he lives all the time in a medical atmosphere of Hospital, 
Dispensary, College, Clinic, and progressive and representative medical men. 
If the country practitioner would keep abreast of the time, he must in addition 
to reading a few thoroughly good journals, take a postgraduate course as 
often as his time and circumstances will permit. All honor to the men and 
women who leave their work and travel hundreds and thousands of miles for 
postgraduate instruction. No other profession can boast of more unselfish 
and honorable instincts than are shown by the rank and file of the medical 
profession in a search for the best and most advanced knowledge in the prac- 
tice of the healing art. 

Hospital and dispensary material is not utilized for the purpose of instruct- 
ing as it should be. The best hospitals are teaching hospitals, and the best 
place to obtain postgraduate instruction in medicine is in a teaching hospital 
which offers bedside instruction all the year round. In addition to the position 
of internes in hospitals there should be a system of externes, or matriculates, 
with a term of service of from three to six months — to act as junior assistants 
or dressers and thus to be brought into intimate contact with the vast material 
of our large institutions. Our city hospitals should have a country branch 
with a large corps of dressers 9,nd assistants for the treatment of subacute 



INTRODUCTION 7 

and chronic cases and convalescents. It is love's labor lost to keep medical 
and surgical cases longer in the wards of a city hospital than is necessary. 
Convalescents need sunshine, good air, exercise, hydrotherapeutics, and the 
like. Well to do convalescents go to the mountains and seashore if con- 
valescent from acute illness. It would cost less to treat poor convalescents 
in the country, and give better results. The tendency to erect costly and 
elaborate hospital buildings in the city is in many instances a concession to 
our love of outward show and splendor. 

I would venture to express the opinion that all medical men should start 
as general practitioners. If for any reason whatsoever they find it advisable 
to practice a specialty, they will be more generously informed and better 
equipped in every way by reason of years of general practice and experience. 
I predict that the successful general practitioner of the future will be a diagnos- 
tician, sanitarian, and minor surgeon, and after years of active practice such 
a general practitioner will develop into a valuable and conservative general 
consultant. 

Just as the old temple of ^sculapius, held together by a cement of super- 
stition and ignorance, has fallen, and a new temple is being erected, decorated 
with the magnificent works indicative of the progress of our times, so the old 
general practitioner with his obsolete methods and drugs is bound to go — 
and in his place will arise the modern family practitioner, the diagnostician 
and sanitarian, who will find his way along the trails and paths blazed for him 
by the master minds of the past, right into the hearts and confidence of the 
people. 



CHAPTER I 

THE TECHNIQUE OF DIAGNOSIS AND LABORATORY AIDS 
TO CLINICAL DIAGNOSIS 

THE TECHNIQUE OF DIAGNOSIS 

Synopsis: Introductory Remarks. — ^The Causes of Disease. — Diagnostic Inquiry, General 
Examination. — The Patient's Statement of his Case. — Anamnesic Data. — Miscella- 
neous Signs. — ^The Recognition and Grouping of Symptoms. — The Significance of 
Fever and Pain. — The Preliminary Examination of the Urine and Blood. — Regional 
Examination. — Examination with X Rays. — ^Transillumination. — ^Tuberculin Test. — 
Exploratory Puncture and Incision. — Examination under Anaesthesia. — Examination 
of a Comatose Patient. 

INTRODUCTORY REMARKS 

Although a certain amount of material success is possible in the practice 
of medicine by symptomatic management without a clear knowledge of clinical 
pathology, the physician who aims to practise the healing art to the best ad- 
vantage of the patient and with some degree of personal comfort and satis- 
faction must be able to make a diagnosis. 

To select the right path when so many intricate symptoms are present is 
assuredly not easy. The novice in woodcraft who endeavors to find his way 
through an unknown territory over hills and valleys and streams is bewildered 
in the same manner, and must be conteint at first to follow in the footsteps of 
the more experienced guide. 

Modern diagnosis is based upon the recognition of symptoms, regional land- 
marks, and upon laboratory research. As diagnosis has become more scientific 
and exact, the art of medicine has become more practical, owing to the elimi- 
nation of deductive reasoning. In place of the latter, laboratory methods, 
inspection, palpation, percussion, auscultation, direct view with specula, 
lens, and mirror; x rays, exploratory incision, and puncture have furnished 
countless diagnostic possibilities and enabled the practitioner to attain a high 
degree of precision. 

To establish a correct diagnosis may require days. 

Systematic investigation, practice, and experience soon make quite easy a 
task which at first appears difficult, so that he who is fitted by nature to act 
as a medical adviser will in time learn to think and act for himself. It should 
be the aim of every general practitioner to become a good all-around diagnos- 
tician ; and, if he fails in this, let him drift jnto a specialty. 



10 LABORATORY AIDS TO CLINICAL DL\GNOSIS 



THE CAUSES OF DISEASE 

Deviations from normal functions and structure are inherited or ac- 
quired. Hereditary transmission may be temperamental, functional, or 
structural. This includes that imponderable quality known as hereditary 
predisposition. 

Acquired ailments are the result of traumatism (injury), parasitic invasion 
(infection), intoxication, underfeeding and overfeeding, exposure to extremes 
of heat and cold, suppression of internal secretion, and nerve irritation and 
nerve fatigue from divers causes leading to and producing: Faulty meta- 
bolism, functional and reflex disturbances, or tissue changes and organic 
disturbances, ending in restitution to health or in death, at which time the 
animal body has completed the cycle of its destiny. 

It is the duty of the physician: To educate the individual regarding 
preventive measures, determine the nature of an ailment, and look for and 
remove the source of irritation in functional or organic disorders, to aid 
nature in warding off and overcoming the dangers of acute illness, and relieve 
the suffering incident to progressive organic disease leading to dissolution. 

Inasmuch as nature establishes a fair degree of tolerance as regards the 
discomforts incident to acute and chronic illness, very active symptomatic 
treatment, particularly in chronic ailments, is unnecessary and often meddle- 
some and harmful. It may not be out of place to remark that in estimating 
the health or disease status of the individual, we must ever bear in mind that 
a large percentage of persons of all classes come to the physician with imr- 
aginary ills, and that hysterical phenomena and malingering are very 
common. To a certain extent this assertion holds good even in children. 



DIAGNOSTIC INQUIRY 

GENERAL EXAMINATION 

When a patient comes to us for advice, we make, in accordance with cir- 
cumstances and the time at our disposal: 1. A preliminary examination. 
2. A complete clinical examination. 

Occasionally our diagnostic probing is handicapped by the comatose or 
delirious state of the patient, or we are compelled to anaesthetize him in 
order to be able to make a careful regional examination. Finally, it may 
be necessary to open the abdomen or other cavities or puncture a cavity, 
tumor, or organ in order to make an exact diagnosis and suggest and carry out 
proper treatment. Adults are best examined in bed or on a table with most 
of their clothing removed. Children should be completely undressed and 
examined in a good light on a table covered with a pillow or blanket. 

Although the bulk of medical practice is made up of slight ailments, we 
must not forget that general symptoms are not pathognomonic and occur in 
slight ailments as well as in serious illness. 

A diagnosis is made directly or by exclusion by taking into consideration 
the personal and family history of the patient, his subjective symptoms and 
complaints, the findings of a regional examination, and the findings of the 
laboratory. 



DLA.GNOSTIC INQUIRY 11 

In determining what a disease is, the physician must not go beyond the 
simple facts. 

The Patient's Statement of His Case. — After a few friendly remarks for 
the purpose of putting the patient at his ease, we ask for a recital of the present 
illness and subjective symptoms and make direct or indirect inquiry as to 
its probable cause, manner of onset, duration, and previous management. 
In the case of young children the information is given by the parent. Older 
and intelligent children sometimes give a fair history if they are not frightened. 

Anamnesic Data (to be brought out by the physician). — Name, age, sex, 
condition, occupation, nationality, residence. 

Family History and Previous Personal History, as to: Syphilis 
(chancre), gonorrhea, tuberculosis, cancer, rheumatism, gout, malaria, in- 
temperance, insanity, injuries, menstruation, pregnancies, miscarriages, con- 
vulsions, diseases of childhood, and other diseases. 

Habits. — ^Tobacco, alcohol, narcotics, coffee, tea, exercise, environment, 
sexual desire, masturbation. 

Nutrition and Subjective Symptoms. — Quantity and quality of food, 
breast or bottle fed, weight (stationary, gain, loss), condition of tongue, 
appetite, bowels, urinary functions, sleep, fever, pain, cough, vertigo, nausea, 
vomiting, and local symptoms. 

For anamnesic data in nervous and mental diseases, see Neurological 
Memoranda. 

Miscellaneous Signs. — The facial expression may indicate pain, anxiety, 
fear, alarm, vacancy, or stupidity, etc. ; the face of impending death, of ad- 
vanced pulmonary tuberculosis, of mouth breathers, of the "typhoid " status, 
of renal disease, (puffy eyeUds, etc.) ; the facies of dyspnoea (pneumonia 
and pulmonary oedema), of asthma, of exophthalmic goitre, of peritonitis, 
of hysteria. 

Cachexia. — Anaemia, emaciation, and debility are the characteristics of 
cachexia from grave organic disease. The experienced clinician will recognize 
a cancerous, syphilitic, or malarial cachexia, or the cachexia strumipriva, a 
name given to the cachexia resulting from the extirpation of the thyreoid gland 
and characterized by an anamic, myxoedematous skin and neurotic disposition. 

Diathesis. — Clinical experience will enable us to speak of a tuberculous 
(scrofulous strumous), gouty (lithsemic), rheumatic, neuropathic, fatty, haemor- 
rhagic, and lymphatic diathesis. 

The Recognition and Grouping of Symptoms. — After securing the anamnesic 
data in a given case of illness, we look for symptoms. 

The multitude of symptoms deserve a word of explanation. They are 
not, as a rule, pathognomonic of a certain diseased condition, nor do they 
point to specific or distinct systemic disturbances, but are found in trivial as 
well as in serious ailments and are not in themselves the basis for conclusions, 
excepting in connection with regional examination, etc. Nausea, a coated 
tongue, and a general feeling of malaise may be due to constipation, or may 
usher in a tuberculous meningitis or some other infection. A cough is a 
prominent symptom in emphysema or membranous croup or it may be due 
to reflex irritation from a follicular pharyngitis, etc. The underlying cause 
of a supraorbital neuralgia may be syphilis, tuberculosis, or malaria, and so 
ad infinitum. Therefore, the treating of symptoms is an illusion and a snare. 



12 LABORATORY AIDS TO CLINICAL DIAGNOSIS 

For practical purposes we shall group the general symptoms according to 
the systemic or organic disturbance to which they point, viz. : 

1. Pointing to Organs of Digestion: Loss of appetite, fcetor, coated 
tongue, bad taste in mouth, belching of gas, eructations, dysphagia, nausea, 
vomiting, local pain, "dyspeptic asthma," constipation, diarrhoea, flatu- 
lence, tympanites, jaundice, vertigo, headache, phosphaturia, etc. 

2. Pointing to Organs of Circulation: Pallor, cyanosis, flushing, 
oedema, pulsating swellings, dilated and pulsating veins, coldness of hands 
and feet, palpitation, throbbing sensations, arrhythmia of heart's action, 
dyspnoea, local pain, vertigo, circulatory or cardiac "asthma," syncope, 
collapse, etc. 

3. Pointing to Organs of Respiration : Sneezing, coryza, nasal voice, 
loss of smell, hoarseness, aphonia, cough, croupy cough, expectoration, haemor- 
rhage, dyspnoea, noisy respiration, pulmonary or respiratory "asthma," local 
pain, perverse sensations, etc. 

4. Pointing to Genitourinary Ailments and those of the Female 
Pelvic Organs and the Rectum: Retention, suppression, or incontinence 
of urine, vesical tenesmus, painful micturition, haematuria, pyuria, albuminuria, 
impotence, abnormal discharge, haemorrhage, pain in penis or scrotum, dyspnoea 
or asthma of renal origin, etc. Bearing down pain in pelvis, menstrual anom- 
alies, intermenstrual pain, leucorrhoea, etc., constipation, incontinence of faeces, 
rectal tenesmus, haemorrhage, pain in rectum, abnormal discharges, etc. 

5. Pointing to Acute Systemic Infection or Intoxication: General 
aching, headache, chill, fever, thirst, weakness, faintness, insomnia, vomiting, 
herpes labialis, convulsions, coma, etc. 

6. Pointing to Nervous and Mental Ailments : Motor, sensory, tro- 
phic, and reflex disturbances, rectum and bladder and ocular phenomena, 
analgesia, neuralgias, tremor, tics, paralysis, paresis, convulsions, girdle sen- 
sation, abnormal gait, nervous asthma, mind wandering, forgetfulness, in- 
somnia, somnolence, aphasia, polyuria, impotence, globus hystericus, delirium, 
hallucination, coma, etc. 

7. Pointing to Disease of the Blood : Anaemic appearance, purpura, 
haEmophiUa, etc. 

8. Pointing to Organs of Locomotion : Pain, abnormal posture and 
gait, crepitation on motion, muscular rigidity or paralysis, articular rigidity 
or laxity and swelling, false points of motion, etc. 

9. Pointing to the Skin : Itching, burning, discoloration, eruption, and 
other visible manifestations, etc. 

10. Pointing to the Eye : Disturbed vision, headache, eye fatigue on 
reading, burning sensation in lids, dizziness, photophobia, weeping and dis- 
charges, orbital and circumorbital pain, pink eye, etc. 

11. Pointing to the Ear: Previous sore throat, pain and swelling in 
mastoid region, loss of hearing, pain in ear, noises in head or ear, discharges 
from ear, etc. 

12. Pointing to Severe Constitutional Derangements and Grave 
Organic Disease : Loss of appetite, coated tongue, loss of strength and am- 
bition, great loss of body weight, insomnia, appearance of cachexia. 



THE SIGNIFICANCE OF FEVER AND PAIN 13 

The Significance of Fever and Pain 

In order to make a comprehensive presentation of clinical phenomena 
the significance of symptoms will not be discussed in a separate chapter 
and from a diagnostic standpoint, but will receive attention throughout the 
book in connection with the various ailments. At present we shall consider 
only Fever and Pain as general phenomena which we may encounter in any 
and almost all forms of illness. 

Fever. — The normal bodily temperature is 98° to 99° F. The rectal tem- 
perature is about one degree higher than that of the mouth or axilla. For 
taking temperature the clinical thermometer should be inserted into the 
rectum or vagina or under the tongue with lips closed. The temperature 
record taken in the axilla is not reliable. 

To convert the Centigrade into the Fahrenheit scale we divide the Centi- 
grade temperature by 5, multiply the quotient by 9 and add 32. To convert 
the Reaumur scale into Fahrenheit we divide by 4, multiply by 9 and add 32. 

Fever is characterized by rise of body temperature plus a disturbed 
metabolism. A normal temperature is maintained by means of a complicated 
system of heat regulating apparatus the details of which are more of physio- 
logical than clinical import. An increase of body temperature is usually 
accompanied by a respiratory increase. In fever there is a contraction of 
surface capillaries; the skin cools off and the patient experiences a chilly 
feeling, chills. We also observe chills with fever temperature and a reddened 
skin with dilated capillaries. A nervous chill is unattended by rise of tem- 
perature. An increase of body temperature is usually accompanied by an 
increase of body oxidation, particularly albumin oxidation; and thus we find 
in the febrile state an increase of urea in the urine. 

In the convalescent stage of acute infectious disease, the regulation of the 
body heat is liable to be disturbed by trivial causes. Thus, in typhoid con- 
valescents a rise of temperature is observed when nourishment is taken in 
excess. 

In order to produce fever by infection, bacteria or their products must enter 
the circulation. The same holds good for the protozoa (malaria). We 
have no definite knowledge regarding the purely nervous irritation of the 
heat centres. The predisposition to fever temperature varies with the in- 
dividual and with his age and condition of the individual. This is a well 
known clinical fact. Young and strong individuals have a higher range of 
fever heat than the weak and aged. As a rule, continued high fever is accom- 
panied by loss of appetite and inanition. Here, again, there are exceptions. 
The writer has known children and adults to have temperatures of 104° for 
over a week and still retain an excellent appetite. 

Continued high fever is accompanied by structural change in the liver, 
kidneys, heart, and muscles. Frequently, a loss of body weight is not observed 
during the fever period, but is noticed during convalescence. 

The significance of fever for the organism is still a mooted question. On 
the one side fever is looked upon as a direct danger, and, contrariwise, a high 
temperature is looked upon as favoring a limitation of disease conditions. 
Naturally, our therapeutic efforts will vary according to our personal con- 
ception of such conditions. At the present time we are still in the dark regard- 



14 LABORATORY AIDS TO CLINICAL DIAGNOSIS 

ing these points and we do not exactly know whether a fever from an infection 
is favorable or unfavorable or of neutral importance to the animal economy. 
Thus our antipyretic efforts through hydrotherapy or chemical antipyretics 
may or may not be of value in a given case, but may be rational as favoring 
increased elimination through the skin, etc. Our knowledge regarding sub- 
normal temperature is meagre. 

The temperature is a very important aid to diagnosis. A fever tempera- 
ture may mean very little, but it always means something, and should stimu- 
late us to look for and, if possible, to find the cause. A single notation of 
temperature is not of much value in obscure disease, and it frequently becomes 
necessary to study the temperature curve extending over one, two, or more 
weeks. A daily remission to the normal usually excludes typhoid fever and 
speaks for malaria. Unresolved pneumonia and tuberculous pneumonia show 
a marked difference in the temperature curve. A sudden rise of temperature 
following an operation puts us on our guard for a complication. Mild abdomi- 
nal symptoms and a low fever curve in children, in the absence of a painful 
appendix and of Widal's typhoid fever reaction, are suggestive of tuberculous 
peritonitis. Thus, in obscure cases, the patient, if not in a hospital or under 
the care of a trained nurse, must be taught to take and note his temperature 
several times a day. According to the writer's observations, adults and chil- 
dren with valvular heart lesions sometimes have a " normal " temperature 
of 100° F. In acute indigestion in children very high temperatures are ob- 
served, and some children show very high temperature from any slight cause. 
The term aseptic fever is sometimes employed by surgeons to designate a 
rise of temperature following an operation which can not be localized as to 
cause and which is unaccompanied by other symptoms of septic infection. 

Clinically, high temperatures have been observed in tetanic muscular con- 
tractions, in infectious diseases, in insolation, and in lesions of the bulbocervical 
cord. In acute illness the temperature may be taken every four hours or at 
the time of a chill. In chronic illness once or twice a day is sufficient. The 
various types of fever — continued, remittent, intermittent, irregular, etc. — 
will be mentioned in their clinical relations to disease. 

Pain; Tenderness; Paraesthesia ; Headache. — Pain may be acute or dull 
or paroxysmal or shifting — gnawing or crampy or tenesmic or pulsating. It 
may increase by motion and disappear on firm pressure. 

Pain, as a symptom in children and adult neurotics, is not always a reliable 
factor on which to base a conclusion. The cause or origin of a given pain is 
to be made out by the associated signs and symptoms. It is generally true 
that if we elicit tenderness in an organ that organ is disordered. It is important 
to note the character and the seat of pain. It must not be forgotten that we 
meet with many instances of pain quite remote from the seat of the trouble 
which produces it, i.e., children frequently complain of pain in the abdomen 
in pneumonia or pleurisy. 

Pain in joints and muscles is easily made out on motion and is as readily 
simulated. Pain in vomiting and defaecation and urination or coughing is 
usually characteristic owing to posture and expression. The hydrocephalic 
cry is characteristic. Intestinal, renal, biliary, and appendicular colic, gastro- 
intestinal neuroses and crises, and pains from intestinal worms and pelvic 
adhesions are not always easily distinguished from one another. The agoni- 



REGIONAL EXAMINATION 16 

zing pain of angina pectoris is characteristic. Pain in the region of the heart 
or kidney is usually muscular. When children have pain in the ear they 
hold their hand to the affected side and the head is held in a strained position 
on account of indurated and painful lymph nodes behind the ear. 

Certain forms of disease have characteristic points of pain on pressure, 
which are mentioned elsewhere. 

The diagnostic import of the seat of pain can not be scheduled, but its 
exact location is very important in diagnosis. Headache is a symptom of 
viultiple origin and deserves special mention. A localized neuralgic headache 
or pain is frequently of malarial origin, but may also be due to local irritation. 
A dull general headache and coated tongue are generally due to indigestion. 
Headache may be of reflex character and take its origin in any disturbance 
of the bodily functions — circulatory, digestive, respiratory, eliminative, or 
excretory. It may accompany acute and chronic infection or take its origin 
in the nervous system — from fright, in injury, from hunger or fatigue, from 
eye strain, from disease of the sexual organs, from nasal irritation, from bad 
teeth, or from anaemia or hysteria. Persons who live in overheated and ill 
ventilated rooms are subject to headache. 

In para;sthesia there are subjective sensations such as formication, itching, 
bearing down, numbness, burning, cold and heat, girdle sensation, praecordial 
tightness and constriction, which will be discussed in their relation to special 
diseases. 

The Preliminary Examination of the Urine and Blood. — After eliciting 
and grouping the symptoms in a given case of illness, we are ready to proceed 
with the special or regional examination in order to ascertain whether we have 
to deal with a structural or functional disturbance. 

Before we begin our regional examination we should, if circumstances 
will allow, make a preliminary examination of the urine. This is of the utmost 
cUnical importance. A qualitative examination of the urine for albumin, 
sugar, and bile can be made in five minutes, and the knowledge it imparts is 
like a guide post at a cross road — it points in the direction of a correct 
diagnosis. 

A preliminary exayyiination of the blood for Plasmodium malarice in febrile 
disease is also important and enables us to inaugurate specific treatment if 
necessary without much temporizing. Whenever a blood examination can 
not be made immediately in a suspected case of " malaria " we may with ad- 
vantage send out a " diagnostic feeler " in the shape of a brisk cathartic com- 
bined with quinine (the therapeutic test). 

REGIONAL EXAMINATION 

It is assumed that the practitioner and advanced student are familiar 
with physical diagnosis methods and with the employment of ordinar}' specula 
and instruments for regional examinations, the use of which can not be learned 
from books, without which knowledge no one is competent to make a regional 
examination. 

A REGIONAL EXAMINATION IS FACILITATED BY GROUPING THE REGIONS 
AND ORGANS IN CONFORMITY WITH MODERN SPECIALISM, AND BY BEARING 
IN MIND THAT WE MAY CONSTANTLY MEET WITH MALFORMATION, INJURIES, 



16 LABORATORY AIDS TO CLINICAL DUGNOSIS 

ACUTE AND CHRONIC INFECTIONS AND THEIR SEQUELS, PARASITIC INVASION, 
AND AN UNLIMITED NUMBER OF REFLEX NEUROSES AND INTOXICATIONS FROM 
WITHOUT OR FROM WITHIN (bY REASON OF FAULTY INTERNAL SECRETION). 

SPECIAL EXAMINATIONS 

Examinations with Rontgen Rays are an established feature in medicine 
and surgery. X ray pictures, like all shadowgraphs, are apt to be deceptive 
and misleading. Stereoscopic or double ray prints are apt to give a clearer 
insight into the actual relation of the parts than plain shadowgraphs. In 
making an x ray exposure, every precaution should be taken to avoid burns. 
In lengthy exposures the tube must be from ten to fourteen inches from the 
skin and the latter may be anointed with vaseline. 

Transillumination of organs and regions by means of condensed light 
occasionally gives definite results. 

The Tubercuhn Test, which is of inestimable value in detecting bovine 
tuberculosis, may occasionally be employed; but in the present state of our 
knowledge the writer does not advocate its routine employment. See also 
article on Tuberculosis of Lungs. 

Exploratory Puncture and Incision are not performed often enough, and 
many a doubtful case could be readily cleared up by such a procedure under 
antiseptic precautions. 

Other Examinations, such as an examination of a patient in a comatose 
condition, are extremely unsatisfactory as a rule. One should be very guarded 
in expressing an opinion in such cases, and emergency treatment is indicated 
without an exact knowledge of the underlying condition. See Coma. 

Finally, cases will be met with in which the practitioner is compelled to 
anaesthetize the patient in order to clear up certain conditions. Hysterical 
contractures and stiff joints are thus detected, and a painful examination is 
made possible by the complete relaxation which anaesthesia affords. When 
ancesthesia is employed for diagnostic purposes, the patient has a right to expect 
that the evidence to he elicited should be conclusive one way or the other. P'or 
laboratory findings, see following chapter. When a positive diagnosis has 
been made the hne of treatment to be adopted is self-evident, and it should 
be carried out on the principle of " non nocere." When the diagnosis is 
"in dubio," the treatment is naturally symptomatic. 



CHAPTER 1— Concluded 
LABORATORY AIDS TO CLINICAL DIAGNOSIS 

Synopsis : List of Apparatus and Chemicals. — Examination of Urine, Faeces and Entozoa, 
Gastric Contents, Sputum, Discharges, Exudates, Transudates, Puncture Fluids, Cyst 
Contents, Breast Milk, Cultures (Bacteria), Blood, Tissues, Calculi. — Drinking Water. 
— Remarks on Cytodiagnosis (cell diagnosis), Cytolysis, Haemolysis, Cryoscopy. — Esti- 
mation of Renal Function by means of Phloridzin. — Directions for Preparing Spec- 
imens. 

INTRODUCTORY REMARKS 

The Laboratory is to the physician what the clearing house is to the busi- 
ness man. Laboratory work is necessary for correct diagnosis. The micro- 
scope shows a series of specific microorganisms, and also changes in tissues 
and blood. Pathological changes in the eliminative organs may often be 
inferred from a clinical examination of various secretions. 

While fine laboratory work is a specialty in itself, the general practitioner 
must avail himself of such laboratory facilities as are at his command. As a 
matter of expediency and convenience the gross analysis of urine, blood, spu- 
tum, and stomach contents can readily be made, as heretofore, in the office. 
The value of laboratory reports depends upon the time, care, and knowledge 
employed in making them. In important cases the knowledge and technique 
of the observer must be beyond question, and the clinician must rank foremost 
in the final adjustment of therapeutic measures. In acute illness, however, 
the proper management of suspected disease should not be delayed until a 
laboratory report is obtained. Many death certificates have been written in 
diphtheria cases because the practitioner waited for a laboratory report before 
giving antitoxine. 

EXAMINATION OF THE URINE 



APPARATUS 



Centrifuge. 

Measuring-glass — graduated. 
Urinometer. 
Test tubes. 
Litmus paper. 
Filter paper. 

Bunsen burner or alcohol lamp. 
Pipettes. 

Esbach's albumin ometer. 
Slides, plain and hollow ground, and cover 
glasses. 

3 



Saccharometer. 

Doremus's apparatus for quantitative esti- 
mation of urea. 

Burettes, pipettes, flasks, beakers, funnel^. 

Microscope, water bottle. 

Platinum wire inoculator. 

Graduated burette, with stand. 

Porcelain dishes. 

Tripod, with wire gauze for heating. 

Thoma-Zeiss white blood cell pipette and 
counting chamber. 

17 



18 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



CHEMICALS 



Bottle No. 2. 



Nitric acid. 

Nitric acid — fuming. 

Acetic acid, 2 per cent. 

Acetic acid, glacial. 

Fehling's reagents. (Purchase ready made.) 
Cupric sulphate. Bottle No. 1. 
Rochelle salt. 
Sodic hydrate 

Nylander's solution: 

Bismuth subnitr 2 parts 

Rochelle salts 4 parts 

Sodium hydrate (stick) 8 parts 

Distilled water 100 parts 

Stain for tubercle bacilli (Ziehl-Neelsen so- 
lution). 

Fuchsin sat. alcoh. sol 1.0 

Carbolic acid, 5 per cent aq. sol., 9.0 

Loeffler's solution: 

Methylene blue sat. alcoh. sol.. . 30.0 
Caustic potash, aqueous sol., 

1-10,000 100.0 



Silver nitrate solution, 5 per cent. 

Sodium hydrate sol., 40 per cent, and dec- 
inormal sol. 

Eosin solution, alcoholic, 1 per cent. 

Bromine, saturated aqueous solution. 

Potassium hydrate sol., 5 per cent. 

Hydrochloric acid, C.P. HCl. 

Ether. 

Chloroform, 30 per cent. 

Sodium hydrate. 

Potassium hydrate. 

Gentian violet solution (alcoholic), satu- 
rated sol. 

Ehrlich's diazo reagents. See page 24. 

Esbach's solution: 

Citric acid 20.0 

Picric acid 10.0 

Water 1,000.0 

Cupric sulphate sol., 2 per cent. 

Five per cent ferric chloride. 

Iodine. Congo red. 



A complete outfit of apparatus and chemicals can be obtained from large drug fimas. 



METHOD OF PROCEDURE IN EXAMINING URINE 

Color. — Wide variation in normal urine. Usually amber colored, light 
or dark according to concentration. The presence of blood gives color from 
carmine to jet black, depending upon amount and upon changes which it 
may have undergone. Bile gives the urine color from greenish yellow to 
greenish brown. Chyle occasionally found in urine makes it milky. Poison- 
ing from carbolic acid and its related drugs makes urine often smoky or black. 
Salol has been observed to make urine green. Rhubarb and senna may give 
a brown or deep red color. Methylene blue makes urine a greenish blue. 

Odor. — Similar to odor of bouillon; more often it is aromatic. When 
undergoing fermentation or decomposition, it has an odor pecuUar to itself — 
the so called "urinous odor," more often foetid and frequently ammoniacal: 

Turbidity. — May be due to urates, phosphates, pus, epithelium, bacteria, 
casts, and chyle in suspension. Persistent turbidity is almost always due to 
pus, most frequently it is due to bacteria; when due to pus alone, the urine 
becomes clear on standing, a greater or less abundant sediment being de- 
posited. Elongated needles of monohydrated magnesium phosphates are 
sometimes found in the urine of persons who have taken magnesia in- 
ternally. Phosphates are precipitated by heat and dissolve on the addition 
of nitric acid. 

Consistence. — Usually fluid. Sometimes presence of pus and mucus 
render it thick and viscid. In chyluria the urine often coagulates. 

Reaction. — Normally acid, intensely so in fevers and in certain diseases 
of the stomach where HCl secretion is diminished; in gout, lithaemia, 
acute articular rheumatism, chronic Bright's disease, diabetes, scurvy, leu- 
caemia, etc. 



CHEMICAL TESTS 19 

Alkaline urine may exist under normal conditions immediately after the 
ingestion of a large amount of food or fruits. Persistent alkalinity indi- 
cates decomposition and usually cystitis. Some drugs — carbonates or or- 
ganic acids — may render the urine alkaline. 

Specific Gravity. — Determined by means of the urinometer and is very 
important, provided a twenty-four hour specimen is tested ; otherwise it is 
of questionable value. Persistent low specific gravity is frequently observed 
in neurotic people, and does not necessarily indicate a chronic nephritis. 
High specific gravity is observed in concentrated urines such as occur in fevers, 
in acute nephritis, and diabetes rnellitus. In diabetes insipidus the urine has 
a low specific gravity. The term diabetes insipidus is a misnomer, because it 
has no connection with true diabetes. The mixture of the whole amount of 
urine passed in twenty-four hours must be had in order to make a correct 
determination of specific gravity. 

The amount voided in twenty-four hours is of importance. Normally, 
the average amount is from one to one and a half litres (40-50 oz.). Wide 
variations may exist in direct proportion to diet, weather, and nervous tension. 

Chemical Tests 

The urine should always be filtered before being tested. 

Albumin. — Heat and nitric acid test: Boil one or two drachms of filtered 
urine in a test tube. If albumin is present a precipitate appears, insoluble in 
a few drops of nitric or acetic acid. Earthy phosphates are also precipitated 
by heat, but these dissolve on the addition of nitric or acetic acid. 

Picric acid test : Overlay a small quantity of urine by a saturated watery 
solution of picric acid. If albumin is present, a deposit, insoluble on boiling, 
forms at the line of junction. 

For an approximate quantitative test use Esbach's albuminometer. 

A large quantity of albumin in urine sometimes causes the urine in the 
test-tube to solidify upon boiling. Albumin is at times present in urine 
physiologically; this is called paroxysmal (cyclic) albuminuria. A highly 
albuminous diet (e. g., eggs) may cause albumin to appear in the urine. After 
severe exertion it is often found; and sometimes it may persist in small 
amounts in the absence of apparent disease of the kidneys. The diseased 
kidney usually causes albumin to appear in the urine. All forms of acute and 
chronic nephritis may cause it to be excreted in considerable quantity. The 
amount depends upon the severity of the exudative process, the state of the 
blood, the venous congestion, and the condition of the capillary walls and 
renal epithelium. In chronic interstitial nephritis the albumin is low in 
amount and may frequently be absent for long periods. In periods of exa- 
cerbation, very large amounts may be excreted. In most febrile diseases, 
transient or continuous albuminuria may be observed and is referable either 
to an acute congestion and degeneration of the renal epithehum, or to an 
acute exudative nephritis. In typhoid fever, pneumonia, meningitis, ulcer- 
ative endocarditis, scarlatina, diphtheria, and smallpox, and all febrile dis- 
eases, also after convulsions, etc., traces are usually found. In yellow fever, 
it is often found twenty-four hours after the onset. It may occur in perni- 
cious malaria, and is nearly constant in cases of irritant poisoning. 



20 LABORATORY AIDS TO CLINICAL DUGNOSIS 

Peptone. — In the form of albumose, peptone is found in the urine in many 
pathological conditions. It is most marked and constant when there is an 
accumulation with more or less absorption of pus in the body, as in empyema, 
celluUtis, suppurative meningitis, resolving pneumonia, and suppurating cavi- 
ties in phthisis; in ulcerative intestinal conditions, such as typhoid fever, 
tuberculosis, dysentery, and carcinoma. It also occurs in scurvy, pernicious" 
anaemia, leucaemia, diphtheria, the exanthemata, acute yellow atrophy of 
the liver, pregnancy, and various nervous diseases (myelopathic albu- 
mosuria). 

For a differential diagnosis, the presence of albumose in urine may be 
of great value to distinguish: 1. Between suppurative and non-suppurative 
processes, especially tuberculous lesions. 2. Typhoid and other ulcerative 
intestinal lesions from catarrhal conditions. 3. Exanthemata, diphtheria, 
etc., from simple fevers. 

The general practitioner requires the aid of a laboratory expert to make 
these more delicate tests. 

Test : a. Separate completely ordinary albumin by boiling faintly acid 
urine. Filter. 

h. Take 50 c.c. of filtered urine, add 5 c.c. of concentrated HCl to acidify. 
Then add 2 or 3 c.c. of 10 per cent phosphotungstic acid until precipitate 
ceases to form. 

c. Heat very carefully in a beaker over a wire-gauze flame until the pre- 
cipitate becomes an ashy gray resinous mass. The fluid is then decanted 
and the precipitate washed twice with distilled water to free it from acid. 

d. Add about 2 c.c. of distilled water and a few drops of 30 per cent 
solution of sodium hydrate to render it alkaline. Dissolve by gentle heat. 
If the solution is not colorless, add more alkali, drop by drop, while boil- 
ing. This fluid now contains a concentrated solution of albumose. The 
biuret test is now employed by adding one drop of a very dilute solution 
of cupric sulphate. The presence of albumose gives a brilliant amethyst 
red color. 

Sug£ir is of significance in the diagnosis of diabetes meUitus. There 
is a transitory physiological glycosuria after the ingestion of a large anjount 
of sugar, and traces are found when digestion is slightly disturbed. Disease 
of the pancreas and liver, some drugs, such as chloral hydrate, morphine, 
alcohol, and chloroform, may cause a slight transitory glycosuria. It is 
found sometimes during pregnancy, also in some nervous diseases, and in 
severe and fatal types of infectious diseases ; also frequently after hysterical 
attacks, emotional excitement, and prolonged anesthesia. 

Fermentation Test : A small piece of ordinary compressed yeast is shaken 
with some of the suspected urine and a test tube filled with the mixture, 
to which some mercury is added. The tube is then inverted into a vessel 
containing mercury and allowed to stand in a warm place (70°-80° F.). 
If sugar be present, fermentation will occur in the course of twelve hours, 
and the carbon dioxide formed will rise to the top of the tube, gradually 
expelling more and more of the urine or the mercury as the amount of the 
gas increases. As the yeast itself, however, may give rise to the forma- 
tion of a little gas in the absence of sugar, as lactose, maltose, and levulose 
also undergo fermentation, and as the internal administration of mercuric 



CHEMICAL TESTS 



21 




chloride, iodoform, salicylic acid, quinine, and other antiseptic drugs may 
stop the fermentation, the test is of value only as a control-test. 
Precautions : 

1. Urine must be faintly acid. 

2. Urine should be diluted so that its specific gravity is approximately 
1008. Allowance must be made in result by multiplying by corresponding 
factors. 

3. Urine should not contain above 1 per cent glucose. 

Fehling's Test is probably most used. There are two solutions. Take 
equal parts of each solution in a test tube, and dilute once with water. Boil, 
add a few drops of urine, and boil again. Sugar gives a brick-red precipi- 
tate. Inasmuch as there are other organic compounds which precipitate 
the cupric sulphate in Fehling's solu- 
tion, a control fermentation test should 
be made; or, for a qualitative test, boil- 
ing with potassium hydrate solution 
seems to be preferable. Urine changes 
from canary yellow to dark brown, 
according to amount of sugar present 
if boiled with this solution. 

Quantitative Test : The quantitative 
test is important to ascertain whether 
the diet and treatment are diminish- 
ing the amount of sugar, even though 
the severity of the disease is not in 
proportion to the amount of sugar. 
Procedure : Remove albumin by precip- 
itating, after acidifying, boiling, and 
filtering the precipitate. Dilute the 
urine from one half to one fifth. Fill 
the graduated burette with the diluted 
urine. Dilute 5 c.c. of Fehhng's solu- 
tion with 40 c.c. of water. Let it boil 
over a wire gauze frame. While boil- 
ing let diluted urine fall in, drop by drop. Remove the flask from the flame 
from time to time to allow the precipitate to settle, and to observe the color 
of the solution. When every particle of blue color has disappeared, read 
the amount of dilute urine used from burette. The amount of sugar can 
be estimated from this formula : 

y : .05: : 100 : x grms. of glucose. 

i/ = number of c.c. of diluted urine used. 

a; = grms. of glucose per 100 c.c. of diluted urine employed. 

Example: If 10 c.c. of urine diluted five times have been used, we have 
used 2 c.c. of urine. Hence, 2 : .05 :: 100 : answer = 2^. 

Why? Fehling's solution is of such composition that 10 c.c. requires for 
complete reduction .05 grm. of glucose. 

Acetone is found in the urine in severe forms of diabetes mellitus, after 
ether anaesthesia, and in those diseased conditions in which there is a high 



Fig. 1. — EiNHORN Saccharometeb. 



22 LABORATORY AIDS TO CLINICAL DIAGNOSIS 

degree of albumin destruction, as in high fever, severe ansBmias, many carci- 
nomas, acute active phthisis, and in disturbances of digestion. 

Test : Pour a few drops of a strong solution of sodium nitroprusside into 
a small amount of urine in a test tube, and make it markedly alkaUne. At 
first a purplish red color appears, gradually turning to yellow. Add two to 
three drops of acetic acid. The presence of acetone gives a color ranging 
from carmine to a purplish red. 

Diacetic Acid and )3-0xybutyric Acid are found in the urine in severe 
cases of diabetes mellitus. 

Test : Add strong ferric chloride solution to unboiled urine until all 
phosphates are precipitated, then add carefully a diluted ferric chloride 
solution. A Bordeaux red coloration of the urine indicates diacetic acid. 
This coloration will disappear on heating. 

The presence of ^-oxybutyric acid is detected by the polariscope 
after eliminating the sugar by fermentation. The ray of light is turned 
to the left. 

Bile. — Bile in the urine indicates some obstruction to its normal flow. 
It may be detected in the urine before other symptoms of jaundice develop. 

Test : If about half an inch of fuming nitric acid be poured into a test 
tube and a few drops of urine be allowed to float on the top, the presence of 
bile will give at line of contact a play of colors, red and green predominating. 
When the fuming nitric acid comes in contact with the urine and a brown or 
purplish ring forms without a play of color, it indicates the presence of indican. 

Indican. — The presence of an abnormal amount of indican in the urine 
indicates a putrefaction of albumin somewhere in the body tissues or in the 
body-cavities, usually of bacterial origin. Indican is almost invariably 
formed in the intestinal tract (ileum) as the result of proteid putrefaction due 
to bacterial action, probably the colon bacillus. 

7\st : To 5 c.c. of concentrated hydrochloric acid and 5 c.c. of urine add 
four drops of a half per cent solution of potassium permanganate in water 
and 2 c.c. of chloroform. If the solution is blue after shaking, indican is 
present. The intensity of the color indicates the relative amount of indican 
in the wine. 

Mucus. — The presence of mucus in the urine in abnormal amount indicates 
an inflammation along the urinary tract, generally a cystitis. 

Test: Noticed as cloudiness throughout the urine, which has been allowed 
to settle slightly. Under microscope it is seen as numerous shreds, clumps, 
or masses, hyaline in character. If urine containing a fair amount of mucus 
be acidified and boiled, we get a cloudiness similar to that given by albumin. 

Haemoglobin. — The presence of small amounts of blood in the urine, or 
derivation from the red blood cells can be demonstrated by testing for 
haimoglobin, or its derivatives, with the polariscope. 

Color test : To a small amount of urine in a test tube, add one fourth its 
volume of caustic potash and boil. The earthy phosphates will be precipi- 
tated. The presence of blood gives the flocculent precipitate a reddish brown 
color. If the urine is much pigmented, as by bile in jaundice, the color will 
prevent the reaction. Also look for red blood cells with the microscope. 

Urea. — The normal amount of urea excreted in twenty-four hours is 
from 20 to 40 grms. (450-600 grains). The diagnosis of a chronic interstitial 



CHEMICAL TESTS 



23 




nephritis without exudation is made by the specific gravity and by estimating 
the amount of urea secreted in twenty-four hours. A specimen of urine from 
each of the amounts of urine passed in twenty-four hours should always be 
employed for examination. 

Test : Solution sodium hypobromite. 

I^ Sod. hydrate (30-per-cent sol.), 70 parts ; 

Bromine, 5 parts ; 

Water, 150 parts. 

As the solution keeps only a few days, it should be made fresh each time. 
The sodium hydrate solution and the bromine should be kept separate. 
Fill the apparatus so that when erect no air can enter the tube. The urine 
should be diluted once. This is not necessary unless the 
urine is very concentrated. Take 1 c.c. of urine in the 
pipette, immerse the tip under the bend in the appara- 
tus with great care so as not to allow air to enter, and 
discharge all of the 1 c.c. into apparatus by slowly press- 
ing the bulb of pipette. None of the air behind the 
column of urine should be pressed into the apparatus. 
Allow it to remain for one half hour. Then read 
amount of solution displaced. The number of milli- 
grams of urea marked on tube are displaced by 1 c.c. 
of diluted urine. It is a simple calculation to find the 
total quantity of urea for twenty-four hours in a 
twenty-four-hours' undiluted urine. 

Chlorides.— An increase or decrease of chlorides in 
the urine is of importance. They are increased in poly- 
uria and during absorption of inflammatory fluids. 
They are decreased in starvation or lack of food, in 
vomiting, where little absorption of food takes place, 
in diarrhoea, where there is a serous discharge, and in 
inflammatory exudative processes, particularly where 
there are purulent exudations. This is the most important cause for the de- 
crease in the amount of chlorides. The test for chlorides is indirectly a test 
for purulent inflammations, such as pyaemia, and in pneumonia. The latter 
disease in some of its phases at times simulates typhoid or malaria. The 
very small amount of chlorides excreted in pneumonia may be of differential 
diagnostic value. Indeed, it is said that the prognosis in pneumonia may be 
determined by the amount of chlorides in urine, as in fatal cases there is almost 
a complete absence of these constituents. There is frequently a sUght decrease 
several hours before the crisis in pneumonia, before there is any clinical change. 

Test : Remove albumin by precipitating it by boiling the slightly acidu- 
lated urine and filtering. Take an inch of filtered urine in a narrow test tube, 
cool and acidify with one or two drops of concentrated nitric acid. Add one 
drop of a 5 per cent solution of silver nitrate. A white precipitate is formed 
of silver chloride. 

Quantitative Test for Chlorides : Take 5 c.c. urine, diluted so as to sub- 
due the color. Titrate with decinormal silver nitrate solution, using yellow 
potassium chromate as indicator. End reaction is reached when the orange 




Fig. 2. — Ureometer. 



24 LABORATORY AIDS TO CLINICAL DIAGNOSIS 

red color first becomes permanent. The amount of chlorides may then be 
determined from amount of silver nitrate requisite. 

Diazo Reaction. — This is supposed to be of value in the diagnosis of 
typhoid fever, but it may be absent in many cases. It is present in the worst 
(usually fatal) cases of tuberculosis. 

Test : This test requires two solutions : 

No. 1. Sulphanilic acid, 1.0 

Concentrated hydrochloric acid, 50 . 

Water, 1,000.0 

No. 2. Sodium nitrite, 5.0 

Water enough to make, 1,000. 

Take 5 c.c. of urine in a narrow tube, add 5 c.c. of solution No. 1, then 
add three drops of solution No. 2. Float 2 c.c. of ammonia on top. At the 
point of contact a deep garnet ring will appear and a salmonpink foam on 
shaking. 

Haematoporphyrin, a hamatin derivative, is found in traces in all urines, 
as well as in faeces. Increased amounts in the urine seem to suggest hepatic 
insufficiency. In addition to its having been found in the urine of cases of 
various forms of hepatic disease, hoematoporphyrinuria has been observed 
in cases of phthisis, exophthalmic goitre, typhoid fever. It is also often found 
in intestinal and gastric haemorrhages, in lead poisoning and especially after 
long continued use of sulphonal, trional, and tetronal. Urines containing an 
excess of haematoporphyrin are usually dark red in color ; but the shade may 
vary from a sherry or port wine tint to a dark Bordeaux. 

Test (Simon) : Thirty c.c. of urine are treated with an alkaline solution of 
barium chloride. The precipitate, after having been washed with water, and 
then with absolute alcohol, is extracted with ordinary alcohol, acidulated 
with hydrochloric acid, by rubbing in a mortar. The solution thus obtained 
will present a reddish color in the presence of haematoporphyrin, and its fil- 
trate yields the characteristic spectrum of the latter substance, i. e., four 
bands of absorption, of which two are broad and dark and two light and 
narrow. The former alone are characteristic, and frequently the only ones 
visible. One of these extends beyond D into the red portion of the spectrum, 
while the other is situated between B and F of the other two bands. One 
may be seen between C and D, and the other between D and E, nearer E. 



Microscopical Examination of Urine 

Casts. — These are cyHndrical, albuminous bodies derived from blood 
serum and take their shape from the uriniferous tubules below the loops of 
Henle. The different varieties receive their names from their consistency 
and contents. 

Hyaline casts. — Homogeneous, transparent, cylindrical, broader than a 
leucocyte but often much narrower. Their length varies. The border is 
delicate, distinct, and not refracting. The ends are rounded. They are 
found in a large per cent of centrifuged urine, and of themselves are of no 



MieROSCOPICAL EXAMINATION OF URINE . 25 

diagnostic value, but are always abnormal, i. e., they are not a normal con- 
stituent of urine. They are more common in the urine of old persons and in 
people suffering from chronic diseases; also after many conditions causing 
temporary ailments. They are abundant in chronic nephritis in children and 
adults. 

Waxy casts usually indicate an amyloid change in the kidney. They 
are stained a mahogany color by iodine in acid solution. They are usually 
broader than hyaline casts, the edges are sharp, and they are less transparent, 
most frequently opaque. They are found in chronic nephritis, particularly 
amyloid and chronic parenchymatous changes. Their presence is against the 
diagnosis of acute nephritis. 

Granular casts. — a. Finely granular — a hyaline body covered or mixed 
with fine granules of urates. They are of no more importance than hyaline 
casts, but excite suspicion, h. Coarsely granular — are found by the breaking 
down of the bodies of epithelial cells. There may be a httle hyaline substance 
in the body, but the granules usually are so thick as to give the casts the ap- 
pearance of being opaque and yellow. Shreds of epithelial cells may be seen. 
They are of considerable significance and indicate a chronic nephritis or an 
acute exacerbation of a chronic nephritis. It may be some weeks or months 
after an attack before they are found. In centrifuged urine, hyaline casts 
studded with urinary salts present the appearance of granular casts. This 
is not ordinarily the case in gravity sediment, i. e., sediment formed on 
standing. 

Epithelial casts are formed of intact or broken-up epithehal cells. They 
are yellowish, large, broad, opaque, with regular edges, and may or may not 
have a hyaline matrix. All gradations between coarsely granular and epithe- 
lial casts occur. They signify an acute nephritis or an exacerbation of a 
chronic nephritis, and are frequently found in chronic nephritis. 

Pus casts are made up of leucocytes, and are to be differentiated from 
epithelial casts by: (a) Their transparency, (h) their lighter color, (c) the 
absence of characteristic structure. Their presence indicates an acute in- 
fectious exudative nephritis. A purulent nephritis also has pus casts, but 
there are also many cells free in the urine. 

Blood casts are casts packed with red blood cells. Significance : Acute 
nephritis or an acute exacerbation of a chronic nephritis or traumatism. 

Bodies resembling Casts. — Masses of Urates. — The outUne is ragged 
instead of defined ; edges are dark instead of yellow or transparent. 

Cylindroids from urine of cystitis are differentiated by non-uniformity 
in size and shape. They have the same significance as hyaline casts. 

Blood in Urine. — If blood be not diagnosed grossly, it can be recognized 
with the microscope. In the urine, it may come from any portion of the 
genitourinary tract. (See Haematuria.) 

Aloin Test for Blood. — One fifth volume of glacial acetic acid is added to 
suspected material and allowed to stand one half hour. Sulphuric ether, 
one third volume, is then added and allowed to stand one half hour. The 
ethereal extract is decanted into small test tube. A few grains of aloin are 
added. Peroxide of hydrogen or other oxidizing agent is then added, of 
volume equal to that of ethereal extract. A cherry red color indicates 
blood. This test can be used for urine, faeces and stomach contents. 



26 LABORATORY AIDS TO CLINICAL DIAGNOSIS 

Pus in Urine. — Pus is readily recognized in urine by means of the micro- 
scope. It also may come from any portion of the genitourinary tract. If 
associated with pus casts, it probably comes from the kidneys. Pus from 
kidney in pyeUtis is said to occur in httle masses composed of six to eight or 
more leucocytes closely packed together. (See Pyuria.) 

Test for Pus : Add strong KOH to urine. Pour from one beaker to an- 
other several times. The formation of a tenaceous stringy mass is indi- 
cative of pus. 

Epithelium. — This is readily seen and recognized under the microscope, but 
the differentiation in cells from different parts of the genitourinary tract is 
very difficult and requires much experience. The cells from the pelvis of 
kidney are columnar and sometimes round or polygonal, and similar cells are 
found in follicles of the prostate gland. Bladder cells are broader and shorter. 
Large, flat, squamous epitheUal cells from the vagina are found normally in 
urine from the female. 

Spermatozoa. — These are found often in urine of both the female and male 
after coitus, and after a seminal emission. If a urine constantly contains 
spermatozoa, this is an indication of spermatorrhoea. 

Gonococci. — Gonorrhoeal threads can be found in urine by having patient 
urinate in two glasses, and holding the first up to the light, when mucoid 
particles can be seen floating in the fluid. To find the gonococci, it is best 
to take a drop of pus or mucus frorn urethra and stain as described under 
Discharges. They can often be found only in the shreds. 

Tubercle Bacilli. — The tubercle bacillus can often be found in urine which 
has been centrifuged and also frequently in gravity sediment. It closely 
resembles the smegma bacillus and the similarity in their staining properties 
demands decolorization in pure alcohol for about twelve hours. The smegma 
bacillus is decolorized by this treatment. If the urine is carefully drawn 
with a catheter, the smegma bacillus can often be excluded. 

Tjrphoid Bacilli. — This bacillus is almost constantly found in the urine of 
typhoid-fever patients, and is demonstrated by making cultures. Other 
organisms found in the urine are the Micrococcus urese, the different pus cocci, 
actinomycosis granules, yeast cells and mold, colon bacillus, several forms 
of proteus, Staphylococcus aureus and sometimes the streptococcus. 

Parasites in Urine. — A few parasites have been found. The trichomonas, 
amebse, ova of the distoma haematobium, and the larvae of Filaria sanguinis 
hominis. 

Inorganic elements are always found in urine. If the urine is acid, we 
may find crystals of uric acid, urates, and calcium oxalate, or neutral calcium 
phosphate. If the urine is alkaline, we may find crystals of triple phosphate, 
calcium phosphate, carbonates and ammonium urates and calcium oxalate, 
and magnesium phosphate. Leucin and tyrosin are found in the urine in 
poisoning by phosphoric acid, in acute yellow atrophy of the liver, and in 
severe cases of typhus fever and smallpox. 

Test : Evaporate the urine to consistency of syrup and examine under 
microscope for characteristic crystals. 



EXAMINATION OF F^CES 27 

EXAMINATION OF Fi^CES 

CHARACTERISTICS 

Number of Stools. — The normal number is one stool a day. Three in 
one day or one in forty-eight hours may not be an indication of a pathological 
condition. 

Reaction whether acid or alkaline is not significant. 

Amount. — The amount varies in proportion to the solids ingested. The 
average is 60 to 250 grams in twenty-four hours, of which about 75 per cent 
is water. 

Consistence. — The consistence varies from the watery discharges in cholera, 
to the hard, scybalous masses of chronic constipation, and depends largely 
upon the amount of fluids ingested and the condition of the digestive tract. 

Odor. — The natural offensive odor of fieces is due to albuminous decom- 
position and the resulting principles: indol, skatol, phenol, ammonia, fatty 
acids, hydrogen sulphide, etc. Some odors are characteristic, such as those 
of fatty diarrhcEa in children, some alcohoHc stools, in chorea and in amebic 
dysentery. 

Color. — The normal color varies according to the character of the food 
and the amount of pigment derived from bile. In infants, fat and undigested 
milk gives to the stools a whitish color tinged with bile pigments. In adults 
the color is usually brownish yellow. 

Green stools are seen after taking calomel and on exposure to air. Such 
stools are usually acid. 

Black or very dark stools may be due to a meat diet, huckleberries, red 
wines, iron, manganese, and bismuth. Many stools containing old blood are 
dark or black. 

Yellow stools may be caused by the ingestion of santonin, rhubarb, and 
senna. Typhoid stools are yellowish, having received the name of " pea soup 
stools." 

White or clay colored stools are due to alcoholic conditions in which there 
is an obstructive jaundice. 

The Gnielin reaction for bile (the play of colors when the fluid being treated 
comes in contact with fuming nitric acid) is not found in normal stools. If 
found, it indicates disturbance in the small bowel (active intestinal catarrh 
in children). The presence of leucocytes, epithelial cells, mucus, and bacteria 
give the whitish, so-called "rice water" stools. Rupture of an abscess gives 
a whitish or yellowish stool (pus). 

Much recognizable detritus may be observed in stools. This is composed 
principally of imperfectly masticated or accidentally swallowed vegetable 
products, such as orange cells and strings of spaghetti, which are sometimes 
mistaken for parasites. Glittering white deposits or streaks are composed 
of long crystals of fat derivatives. 

Foreign bodies of nearly every description, and gall stones, are found by 
passing fluid faeces through a sieve. Greasy, translucent, jagged calculi are 
due to the crystallization of cholesterin ; dark brown, heavy, and hard 
calculi may be formed in the intestines and passed in the faeces. Calculi 
containing calcium salts are opaque, usually light colored, brittle, and have 
rough granular surfaces. 



28 LABOPIATORY AIDS TO CLINICAL DIAGNOSIS 

Mucus in different forms, according to the portion of the intestines 
where it is secreted, is often found in the faeces. If abundantly formed in the 
small intestine and upper colon, it is well mixed with bile pigment, epithehal 
cells, leucocytes, and food detritus. In coUtis, mucous masses are well sepa- 
rated from the other constituents. In inflammatory conditions of the rectum, 
discrete masses of mucus may be adherent to the surface of the stool. 

Casts of part of the intestinal tract, or cylinders of thick, white mucus 
resembling fibrin are diagnostic of membranous enteritis. These mucous 
masses are from several inches to a foot in length and may be spirally twisted 
or ribbon shaped. They often resemble a tapeworm, for which they have 
sometimes been mistaken, and are of the consistence of jelly. 

Pus often occurs in faeces from rupture of a tubal or supravaginal abscess 
or from appendicitis. In ulcerative colitis or carcinoma of the rectum much 
pus is seen in the dejecta. 

Blood in the stool differs in appearance according to the location in the 
digestive tract from which it comes. When from the stomach, the action of 
the gastric digestion causes it to appear in the form of fine granules, giving a 
grayish 'black color to the stool. Rarely, gastric blood gives a tarry stool. 
Tarry stools with some lumps of blood undissolved, may occur in duodenal 
ulcer. Ulcers of the ileum are usually attended by stools of pure blood, 
or by blood well mixed with the faeces, retaining more or less its red color. 
From an ulcerative colitis, red blood cells are nearly always found in shreds 
of mucus which are blood stained. In haemorrhages from the colon, if large, 
and from the rectum the blood is very little changed. 



MICROSCOPICAL EXAMINATION OF FyECES 

Muscle Fibres. — These are found with striations preserved or reduced to 
colorless, homogeneous, translucent, oval or elliptical bodies. Starch grains 
usually appear as coarse, refractive bodies which turn blue or brown when 
treated with diluted nitric acid and Gram's solution. 

Fat may be seen as fat globules, in crystaUine forms, or in cholesterin 
plates. Normal stools nearly always contain some fat, but strictly speaking, 
this is not a fat, but when present in large quantities it often indicates a 
diminished production of pancreatic juice and bile, and is characteristic of 
some acute and chronic diseases of the small intestine. 

Coagulated proteids, vegetable cells, and diatoms are often noticeable in 
the stools. Pus cells more often indicate an ulcerative process than a simple 
catarrh. Blood cells can frequently be found when a gross inspection of the 
stool fails to reveal the presence of blood. Epithelial cells in the stools may 
often be of great importance. A few may be found in normal stools, but in 
catarrhal conditions they are very abundant. In cholera the stools are 
largely composed of serum, epithelium, leucocytes, and bacteria. 

In typhoid ulcers, epithelial cells and shreds of necrosing tissues may be 
found. A diagnosis between catarrhal and ulcerative processes may be made 
by finding clumps of epithelial cells, adherent leucocytes, and blood cells in 

' The solid contents of faeces can be collected by means of a flour sifter rotating 
in water. 



MICROSCOPICAL EXAMINATION OF F^CES 



29 



the masses of mucus discharged from ulcers. Shreds of malignant new growths, 
with their atypical cells, can help in diagnosis. 

Crystals of the fatty acids are very frequent, and cholesterin occasionally. 
They seem to be of no significance. Charcot-Leyden cnjstals are sometimes 




Fig. 3. — Scolex and Segments of T^nia Saginata. (Wuod.) 




found in abundance and are said to be present in the faeces in people who are 
known to have intestinal parasites. 

Calcium oxalate, sulphate, and phosphate are found, especially after a 
vegetable diet. Triple phosphates also are found very often, and are associated 
with alkaline diarrhoeal stools. Bismuth gives typical black crystals, and altered 
blood gives hoematoidin crystals of a brownish-red color. 

Bacteria and Protozoa in Faeces. — There are many microorganisms in 
the intestinal tract, some of which ordinarily are harmless, but under certain 
conditions become pathogenic. Some are 
distinctly harmful and seem to cause the 
diseased conditions. 

The Bacillus coli communis is con- 
stantly present in the faeces from all parts 
of the intestine in health as well as in 
disease. It has been found exclusively 
in cases of appendicitis, peritonitis, em- 
pyema of the gall bladder, nephritis, 
pyelitis, cystitis, and occasionally in 
pyosalpinx. 

The Bacillus lactis aerogenes and the 
Proteus vulgaris (also found normally) are 
present in many cases of cholera infan- 
tum. The distinctly pathological bacteria of faeces are the Bacillus typho- 
sus in typhoid fever, which can be isolated by plate-culture during the first 
few days of the fever; the Comma bacillus present in Asiatic cholera; the 
Streptococcus pyogenes which is probably the etiological factor in some forms 
of enterocolitis; the Bacillus dysentericus (Shiga bacillus), and the tubercle 





Fig. 4, — Taenia Solium. 



30 



LABORATORY AIDS TO CLINICAL DL^GNOSLS 



hadllus. The Ameha dysenterice is very probably the specific germ of one form 
of colitis, particularly that type associated with hepatic abscess. They so 
much resemble an epithelial cell that an absolute diagnosis 
can be made only by seeing them moving under the micro- 
scope. In order to keep them alive long enough for 
examination, the defaecation must be received in a warm 
pan, and the slide must be warmed. The question as to 
the pathognomonic relation of ameba to diarrhoea is by 
some still considered an open one. 

WORMS 

Tcenia solium, or pork tapeworm, is nort uncommon. 

The head is provided with booklets. Tcenia saginata, or 

beef tapeworm, is the 

one usually seen. 

Bothriocephalus I a - 

tus, or the fish tape- 
worm, is rare in this 

country. The head 

is not provided with 

booklets. Tceniaechi- 

nococcus, although 

living in the intesti- 
nal tract of the dog, 

may enter man by 

means of its eggs, 
and produce cysts, particularly in the liver. The head is covered with 
little booklets which, if separately found, are diagnostic of its presence. 





Fig. 5. — T^nia 
echinococcus. 
Magnified 20 dia- 
meters. (Braun.) 



Fig. 6. — Contents of an Echinococcus 
Cyst showing Scohces, Hooklets, 

AND ChOLESTERIN CRYSTALS. 





(l 



Fig. 7. — Ascaris Lumbricoides 
(Roundworm). 



Fig. 8. — OxYtrRis (Pinworms). 



CLINICAL EXAMINATION OP THE STOMACH CONTENTS 31 

The Nematodes. — Ascaris lumbricoides, or roundworm, is common in chil- 
dren. It measures from six to sixteen inches in length and may wander all 
along the intestinal tract and produce indefinite nervous symptoms. Oxy~ 
uris vermicularis, thread or pinworms, are found in the lower ileum, colon, 
and rectum. They may cause intense pruritus. Anchylostomum duodenale 
and the Trichocephalus dispar s. hominis are also found, and are supposed to 
produce profound anaemia. 

Although the chemical examination of the faeces is important, our present 
knowledge is not sufficient for it to be of much cHnical significance. 

CLINICAL EXAMINATION OF THE STOMACH CONTENTS 

APPARATUS 

Stomach tube. 
Three beakers. 
Long c.c. pipette. 
Porcelain evaporating dish. 
Litmus paper. 

Titrating apparatus : a graduated pipette on a stand with a stopcock at 
the base permitting the flow of the decinormal solution drop by drop. 

CHEMICALS 

Solution phlorogludn vanillin. (Giinzberg's Test.) 

I^ Phloroglucin, 2 parts; 

Vanillin, 1 " ; 

Absolute alcohol, 30 " . 

FLUIDS REQUIRED FOR GETTING THE TOTAL HYDROCHLORIC ACID IN 

STOMACH CONTENTS 

1. Amidobenzol, 5 per cent alcoholic solution. 

2. Alizarin, 1 per cent aqueous solution. 

3. Phenolphthalein, 1 per cent alcoholic solution. 

4. Three beakers, each containing 5 c.c. of filtered stomach-contents 
and each diluted with an equal quantity of distilled water. 

5. Decinormal solution of sodium hydrate. 

Method of preparing a decinormal NaOH solution : Dissolve 63 grms. of 
oxalic acid C. P. (accurately weighed) in distilled water, bringing the solution 
up to one Hter at a temperature of 60° F. (15° C). Dissolve about 40 grms. 
NaOH (C. P.) in distilled water and bring the solution up to one liter. 

Place 10 c.c. oxalic-acid solution in a beaker, add one drop of phenol- 
phthalein, and titrate from a burette with the soda solution. 

If it takes 9.5 c.c. of the soda solution to neutralize 10 c.c. of oxalic acid, 
5 c.c. of water must be added to each 9.5 c.c. of the soda solution to render 
it of the standard normal strength, and to 950 c.c. of soda solution 50 c.c. 
of water must be added. Water may readily be added in whatever proportion 



32 LABORATORY AIDS TO CLINICAL DIAGNOSIS 

is found necessary. Nine parts of water added then to one part of the normal 
gives the decinormal solution. (Ewing.) 

Gross Appearance. — Food products in early stages of digestion, such as 
milk curds, particles of meat, vegetable detritus, are readily recognized by 
the naked eye. 

Mucus appears in nearly all vomitus as thin, translucent, stringy masses. 
In chronic gastritis more opaque mucus and more uniformly mixed with 
food is found. Blood is sometimes streaked, clear, and unchanged through 
vomitus in acute gastritis. Fresh blood is seldom seen in vomitus, as its 
presence in the stomach for only a few minutes changes it to a dark brown 
color. This is not true of the larger haemorrhages, as from the rupture of 
a blood vessel. The usual vomitus from an ulcerating carcinoma resembles 
coffee grounds in form and color. 

Where pyloric obstruction and dilatation of the stomach exist, large quan- 
tities of a blackish fluid may be vomited, the color of which is due to old and 
greatly altered blood. Bile frequently discolors the vomitus, especially after 
long straining at emesis, giving a color from yellowish to greenish. Pus, 
from rupture of a neighboring abscess, may appear in large quantities. Fcecal 
matter appears when there is intestinal obstruction. Roundworms are rather 
frequently seen in vomitus, and Oxyuris vermicularis and Anchylostoma duo- 
denale very rarely. 

MICROSCOPICAL EXAMINATION 

The following may be looked for: 

Muscle fibres with striations as oval, elliptical, yellowish or colorless, 
slightly refractive bodies; a great variety of vegetable cells and starch grains, 
with concentric layers and reacting to iodine; fat in globules or as crystals; 
blood in cells, as hsematoidin, or as masses of pigment; leucocytes, recognized 
by their opaque granules and small refractive polymorphous or multiple 
nuclei; epithelium, columnar from stomach and squamous from oesophagus 
and mouth, found in the masses of mucus. In acute gastritis, epithelium 
may be very abundant. Particles of mucous membrane in chronic gastritis 
and shreds of tissue from ulcerating carcinoma may often be found after 
careful search. Yeast occurs in groups of three or more round or elliptical 
refractive bodies about the size of red blood cells. They frequently show 
several small buds. Sarcinse are cocci growing in cuboidal packets of eight 
individuals or multiples of eight. Bacillus acid lactici, connected with fer- 
mentation, and the Streptococcus pyogenes, associated with some infectious 
cases of acute gastritis, have been isolated. The Oppler-Boas bacillus is 
found in stagnating stomach contents free from hydrochloric acid and not 
rich in lactic acid. By some authorities it is considered of diagnostic value 
in carcinoma of the stomach. 

CHEMICAL ANALYSIS 

Ewald's test breakfast is generally used. It consists of 30 to 70 grammes 
(2| oz.) of white bread and 10 oz. of water. The test meal is to be given in 
the morning on an empty stomach. If there be retention of food, the stomach 
is to be washed out the evening before. One hour after eating the test meal. 



CHEMICAL ANALYSIS OF STOMACH CONTENTS 33 

the contents of the stomach should be expressed or siphoned off. To the 
filtered contents the following tests should be applied: 

Acidity, by litmus or Congo red paper. Free hydrochloric acid by Ginz- 
berg's reagent. The reagent is thinly spread and evaporated over a clean 
porcelain dish. A few drops of the stomach contents are added and the dish 
gently heated over the flame. If there is free hydrochloric acid, a carmine- 
red color appears along the edge of contact of the stomach fluid. 

Combined HCl and total amount HCl. The method of obtaining total 
productions of hydrochloric acid is based upon the sensitiveness of certain 
coloring reagents to the various acid principles found in stomach contents. 

(a) Dimethylamidoazobenzol (or Toepfer's reagent) reacts only to free 
inorganic acids, such as free hydrochloric acid. 

(b) Alizarin reacts to: 

Organic acids (lactic, butyric, etc.). 

Acid salts. 

Free, but not loosely combined HCl. 

(c) Phenol phthalein reacts to: 

Organic acids. 
Acid salts. 
Free HCl. 
Combined HCl. 
It has been found that 1 c.c. of decinormal soda solution neutralizes 
.00365 gramme of HCl. If 5 c.c. of decinormal soda solution are required 
to produce the final reaction with amidobenzol, the fluid contains 5 times 
.00365 grammes of free hydrochloric acid. 

The combined hydrochloric acid may be found by subtracting the quan- 
tity required in the second titration (with alizarin) from that required in the 
third (with phenolphthalein) ; for, by consulting the foregoing lists, it will 
be seen that: 

6 — 6 = the combined hydrochloric acid. 

Hence, as a working formula, we may take the following: 
Titration to get a = free HCl. 
" " c = total acidity. 

" " 6 = inorganic acidity (all acidity except combined 

HCl). 

Total acidity c, minus inorganic acidity 6 = combined HCl, which, united 
to a (the free HCl) gives the total production of hydrochloric acid. 

Method of Procedure : To one beaker, containing 5 c.c. of filtered 
stomach contents, diluted once, add one to two drops of amidoazobenzol 
solution, which, in the presence of HCl, immediately turns a bright red color. 
From the graduated burette decinormal soda solution is carefully added until, 
upon agitating the beaker, the fluid begins to turn to an orange yellow color. 
Soda solution is further added, drop by drop, until all traces of red have dis- 
appeared and the fluid is a bright lemon color, which indicates the final re- 
action. The quantity of soda solution used is noted, from which is computed 
the amount of free hydrochloric acid present. 

To the second beaker, one to two drops of alizarin solution are added, and 
the titration conducted as above. The final reaction is indicated when a deep 
4 



34 LABORATORY AIDS TO CLINICAL DIAGNOSIS 

violet color is reached. From the amount of soda solution used may be 
computed the acidity due to all acid principles except loosely combined HCl. 

To the third beaker, one to two drops of phenolphthalein solution are 
added and it is titrated as before. The final reaction is indicated when the 
rose color fii*st appearing no longer darkens on further addition of soda solu- 
tion. From the amount of soda solution used the total acidity is computed. 

Significance of Changes in the Amount of HCl in Stomach. — If the normal 
amount is found (.1 per cent to .2 per cent), it is strong evidence against 
any organic disease of the stomach. The symptoms referred to the stomach 
when a normal amount of HCl is present must be due either to a nervous or 
atonic condition. Continuous hyperacidity (over .2 per cent) occurs most 
frequently in neurotic dyspepsia, is very often present in simple ulcer, and 
may often be a symptom of the early stages of a chronic gastritis. It speaks 
strongly against carcinoma except when a simple ulcer is undergoing car- 
cinomatous transformation. Coniimious subacidity (under . 1 per cent) is 
seen in chronic gastritis, especially with dilatation and atony, in some cases 
of simple ulcer with chronic gastritis, and in incipient carcinoma. Anacidity 
is a frequent and persistent symptom of the later stages of chronic gastritis, 
when pepsin is also lacking. When pepsin is present, it may indicate a neu- 
rosis. When other signs are favorable, it speaks strongly for carcinoma. If 
the amount of acidity due to HCl varies markedly, in all probabiUty it indi- 
cates a neurosis. 

Lactic Acid. — The test for lactic acid usually employed is Uffelmann's. 
Although there are sources of error, this test is fairly reliable. Test : Take 
10 c.c. of a 5 per cent solution of carbolic acid ; add 20 c.c. of distilled water, 
and one drop of a 5 per cent solution of ferric chloride. An amethyst blue 
color appears, which may soon change, making it imperative to use the solu- 
tion when fresh. A few drops of the stomach contents added to this solution 
produces a lemon color if lactic acid be present. 

Significance of Lactic Acid. — It is often ingested with food, and forms 
early in digestion when milk or bread have been taken. It is seldom present 
after eating carbohydrates. It is found in traces only during the course of 
non-malignant disease of stomach. It is usually present in larger proportion 
in dilatation with stagnation of the gastric contents. If it is associated with 
retention and absence of HCl it is strongly suggestive of carcinoma. 

Pepsin. — Marked diminution or absence indicates a corresponding dis- 
turbance of the glandular activity. It may exist, however, with a variety 
of lesions. 

Absorption and Motility. — The absorption activity of the stomach may be 
roughly indicated by Penzoldt's test : When 5 grammes of potassium iodide 
are taken in a gelatine capsule, iodine appears in the urine and saliva of the 
normal subject within six to fifteen minutes, while with deficient absorptive 
capacity its appearance is much later. The iodine may be detected by 
applying a few drops of saliva or urine with one drop of strong nitric acid to 
starch paper, which, in the presence of iodine, turns blue or violet. 

Sahli's test of gastric efficiency consists in the use of a pill containing 
a small amount of either iodoform or methylene blue, which is enveloped 
in a small bit of the rubber dam used by dentists, the neck of the little 
bag formed being tied off with the finest obtainable raw catgut. Such a 



I 



SPUTUM 35 

pill is given at the end of the ordinary noon meal and the urine passed at 
stated intervals during the afternoon and evening is either examined in 
regard to the first appearance of a greenish color if methylene blue was used, 
or is tested for the presence of iodoform in case this indicator was chosen. 
The latter substance has the practical advantage that it may be detected 
with equal certainty in the saliva. The appearance of either substance in 
the urine, or of iodoform in the saliva, indicates satisfactory gastric diges- 
tion and a negative result the reverse, the information obtained being, 
according to the author, a sufficient index as to the combined activity of the 
hydrochloric acid and the pepsin. 

The motility of the stomach is best determined by giving a test meal 
at night on an empty stomach, and examining the washings the next morning. 
Normally no traces of ingested food should remain. 

A chemical examination of the gastric contents simply shows us the chem- 
ical composition of the gastric secretion at the time the analysis was made, 
and is simply one factor in the diagnosis, prognosis, and therapeutics of 
digestive disturbances of whatever nature. 

SPUTUM 

GROSS CHARACTERISTICS 

Types of Sputum. — The following special types should be noted: 

Mucoid. — A good example of this is seen in chronic bronchitis. It is light 
in color, slightly translucent, viscid, tenacious, elastic, and very slightly 
aerated. 

Mucopurulent. — Seen in acute bronchitis. The admixture of pus with 
mucoid sputum renders it yellow, opaque, less tenacious and elastic. It is 
more completely aerated. 

Purulent. — In severe broncliitis, tuberculosis, and with rupture of lung 
abscess it may be pure pus. Purulent sputum has more pus than nmcus 
and no viscid quality. 

Bloodstained. — This is seen in acute bronchitis, pneumonia, tuberculosis, 
tumors of the lung and hsemophilia. The blood exceeds the mucus. The 
viscidity is reduced, although the sputa remains coherent. 

Pure blood is expectorated in penumonia, phthisis, ruptured arteries, 
aneurysms, asphyxia, various septic conditions of infants, hsemophilia, trauma, 
and some blood diseases. 

Rusty sputum is peculiar to lobar penumonia. It consists of gelatinous 
pellets of nmcus slightly mixed with pus and uniformly tinged a rusty color. 
This type has been noticed after an attack of acute pulmonary oedema. 

Serous. — This is semifluid. Upon standing, it separates into two layers. 
Such mixtures are common in the terminal stages of bronchitis, in Bright's 
disease, tuberculosis, pneumonia, and endocarditis. 

Pure serum may be expectorated in acute oedema of the lungs, occurring 
in the initial stages of pneumonia or in nephritis with arterio-sclerosis. 

Fibrinous coagula are often mixed with the sputa in chronic bronchitis 
and pneumonia. Fibrinous casts of the bronchi may be expectorated in a 
type of chronic bronchitis. 



36 LABORATORY AIDS TO CLINICAL DIAGNOSIS 

Gangrenous sputum is characteristic of putrefaction and necrosis of lung 
tissue. Prune-juice expectoration, indicating a decomposition of blood, is 
common in pneumonia. Gangrene of the lung gives a most fetid discharge, 
which, upon standing, usually separates into three layers: the uppermost 
being frothy mucus and pus ; the middle, serum ; while the heavier, at the 
bottom, is soUd portions of tissue. 

Nummular sputum is the name given to purulent, coin-shaped sputa coming 
from old cavities with suppurating walls. Bile pigment may stain sputa 
in some of the severe forms of infectious disease and jaundice. Actinomyceces 
in colonies appear as small, white, partly calcified granules and resisting con- 
siderable pressure. Curschmann's spirals can usually be detected by the 
naked eye, as whitish, opaque, spiral, threads, 1 to 10 mm. in length. Masses 
of lung tissue are small, grayish in color, and irregular in outline. Hcema- 
toidin is seen as dark brown particles resisting much pressure. 

MICROSCOPICAL EXAMINATIONS 

Mucus and fbrin appear in smear preparations as fine or coarse reticu- 
lated threads. Red blood-cells have their ordinary appearance. Epithelial 
cells from the mouth are squamous ; from the bronchi or nares columnar 
with or without cilia ; from the lung parenchyma they are rounded, large, and 
usually contain black pigment. In pulmonary congestion from endocarditis, 
the epithelium contains large brownish grains of blood pigment. Leucocytes 
are recognized by their multiple imclei and clear bodies. 

Elastic fibres, occurring singly or in masses showing a distinct alveolar 
arrangement, are recognized as large, wavy, highly refractive threads lacking 
the double contour of vegetable fibre. They can be said to indicate destruc- 
tion of living tissue only when they appear in characteristic alveolar 
arrangement, and are most frequent in tuberculosis. They have also been 
found in bronchiectases, abscesses, and rarely in pneumonia. Charcot- 
Leyden crystals, elongated and diamond shaped, are found in chronic bron- 
chitis. Hsematoidin, fatty acid, cholesterin, calcium carbonate, and triple 
phosphate crystals are also occasionally found. Curschmann's spirals, 
found in chronic bronchitis and asthma, frequently contain a number of 
Charcot-Leyden crystals within the meshes. 

Microorganisins. — Molds, aspergillus, leptothrix, and yeast fungi are some- 
times seen in sputum from phthisis cavities and abscess of the lung. The 
ray fungus is observed in pulmonary actinomycosis. It appears as branching, 
interwoven threads, having swollen or club shaped ends, and can be easily 
demonstrated. Streptococci are frequently found in the mouth, and may 
have no pathological significance. In severe acute bronchitis they have been 
found in large numbers. With staphylococci, they are abundant in sputum 
from cavities. 

Pneumococci (Diplococcus lanceolatus) may often be found in the mouths 
of healthy individuals, but are especially abundant in the expectoration of 
pneumonia. The pneumobacillus of Friedlander is found in a few cases of 
pneumonia. It is encapsulated and resembles somewhat the pneumococcus 
except that it is rod shaped, broader, longer, and has rounded ends. Both 
may be stained by Welch's method as follows, but the latter decolorizes by 



TRANSUDATES, PUNCTURE FLUIDS, CYST CONTENTS 37 

Gram's method. Welch's Method. — The sputum is smeared, dried, and fixed 
on a glass slide by passing through a flame until the slide is as hot as the 
hand can bear. Then flood with glacial acetic acid, which is inmiediately 
drained off. Flood two or three times with aniline water gentian violet 
solution. Wash in a 2 per cent aqueous solution of sodium chloride, in 
which it may be mounted. It must not be washed with water. To prepare 
aniline water gentian violet, which must be used only when fresh, shake nine 
parts of distilled water with one of aniline oil, and filter through filter paper. 
To the filtrate add one tenth as much of saturated alcoholic solution of 
gentian violet. 

Bacillus of influenza is a minute straight rod, with rounded ends, often 
staining more deeply at the ends. This often gives it the appearance of 
diplococcus. It is found in immense numbers, singly or in clumps of one hun- 
dred or more and often within the bodies of leucocytes. They are best dem- 
onstrated by staining five minutes with a weak solution of carbol fuchsin. 

Tubercle bacillus can be found in the vast majority of cases of pulmonary 
tuberculosis. This bacillus grows in slender, straight, or slightly curved rods. 
The younger germs stain uniformly with carbol fuchsin, while the older present 
unstained points resembling vacuoles or spores, and sometimes present 
the appearance of a chain of cocci. They may occur singly, or two or more 
may lie side by side or end to end. Method of staining. — Fix the thinly 
spread sputum upon a glass slide by means of heat. Flood with carbol 
fuchsin for two minutes, gently heating. Wash thoroughly in water, 
and decolorize by flooding the specimen with acid alcohol solution for one 
minute. Wash in water, and counter-stain with aqueous methylene blue 
solution for about one minute. Wash in water, dry in air, and mount in 
balsam. The bacillus appeai-s bright red, and the other parts of specimen 
are blue. 

Micrococcus tetragenes occurs in groups of four and are very frequently 
found in tuberculosis, associated with the tubercle bacilli. When found with 
the latter they are said by Hoch to be an indication of cavity formation. 
They stain readily with all of the aniline dyes, particularly methylene blue. 

The smegma bacillus stains with almost as great a tenacity as the tubercle 
bacillus, and to distinguish it from the tubercle bacillus the specimen must 
be decolorized in alcohol for about eight to twelve hours, after which time 
the smegma bacillus is decolorized. 

TRANSUDATES, PUNCTURE FLUIDS, CYST CONTENTS 

Aids to Differentiation. — Collections of serous fluid in body cavities or 
tissue spaces as the result of mechanical disturbance of the circulation, 
changes in the blood or in the walls of the vessels, unaccompanied by inflam- 
matory phenomena, are true transudates. 

The careful chemical and microscopical examination of the fluid is an aid 
to differentiation between an exudate and a transudate. The specific gravity 
in transudates is usually lower than 1.015, while in exudates it is higher than 
1.018. The albumin content in transudates is less than in exudates. In 
the former it averages between 1 per cent and 2.5 per cent and in the latter 
4 per cent to 6 per cent. As exudates are infljimmatory in ori^n, we expect 



38 LABORATORY AIDS TO CLINICAL DIAGNOSIS 

to find the products of inflammation, pus, epithelial cells, microorganisms, 
etc., while in transudates these elements are not usually present and occur 
only after long standing and introduction of infectious elements from without. 
Cyst contents may show the echinococcus hooklets, which are diagnostic. 

EXUDATES 

Exudates are inflammatory in origin, and their examination can aid as 
to the cause of inflammation. They may be serous, bloody (haemorrhagic), 
fibrinous (serofibrinous), purulent (seropurulent), or chylous. Chyloid ex- 
udates differ from the chylous in that they contain much less free fat. 
The turbidity is due rather to cellular debris and lecithin. They may 
coagulate in the cavity or after aspiration. Microscopical examination is 
most important for the detection of isolated cells, or larger particles of a 
tumor, or of tubercle bacilli, gonococci, or other pyogenic microorganisms. 

Tuberculous exudates are usually serous or hsemorrhagic, the latter form 
indicating more severe inflammation. A hemorrhagic pleuritic exudate is 
usually tuberculous, and pleuritic exudates are more usually bloody than 
those of the peritonaeum. Bacilli are present in tuberculous exudates in very 
small numbers, but in the necrotic foci they are more abundant. Rarely 
they may be found by staining the sediment. The best test, however, is 
inoculation into the peritoneal cavity of a guinea-pig. 

Carcinoma or endothelioma of serous membranes is frequently accompanied 
by an exudate, which is usually serous, but often bloody. Isolated cells, or 
small masses of tumor, may be found in the sediment; but the cells must 
show the mitotic changes under the microscope to give a positive diagnosis. 
The diagnosis can frequently be made upon this basis of the presence of 
atypical epithelial cells alone. 

Joint fluids usually contain mucus and are viscid. The exudate of 
traumatic or rheumatic synovitis is usually clear and sterile ; while in tuber- 
culous synovitis the fluid may be bloody or seropurulent, and tubercle bacilli 
may be demonstrated. In gonorrhceal synovitis fluid is serous or seropurulent 
and the gonococcus may often be demonstrated. 

Discharges. — The gonococcus occurs principally in genitourinary dis- 
charges, but may be found in gonorrhceal infections of the rectum, mouth, 
eyes, serous cavities, and also in the blood. The usual location, however, 
is in the genitourinary tract, where it grows on surfaces lined by columnar 
epithelium. In the male, the gonorrhceal germ is found in acute and chronic 
urethral discharges. In gonorrhceal cystitis it is found in the threads, so- 
cafled "gonorrhceal shreds." In the female it is most abundant in and 
often limited to the urethral pus. Next in frequency it is found in the dis- 
charges from the cervix uteri. In the vaginal discharge other diplococci are 
often present, which makes differential diagnosis difficult. Hence it is always 
better to take the pus from the urethra or cervix. In female children the 
gonococcus is often found in the vaginal discharge, but seldom in the ure- 
thra. Children do not usually have gonorrhceal cystitis. 

In looking for the gonococcus, we must note the following characters : It 
nuist be a biscuit shaped diplococcus. It must be found within bodies of 
pus cells. It must be decolorized by Gram's method. 



EXUDATES AND DISCHARGES 39 

Gram's method of staim/ng gonococd: 

The pus is smeared and fixed on a glass slide. Flood the specimen for 
60 seconds with aniline water gentian violet, and blot off. Flood with 
Gram's iodine solution for one minute, and blot off. Decolorize in alcohol, 
97 per cent, for two to four minutes. Counter-stain in saturated aqueous 
solution of Bismarck brown for one to three minutes. The biscuit shaped 
gonococcus is then seen stained brown within the cell bodies of the 
leucocytes. 

The anthrax bacillus is present in large numbers in the exudate of malig- 
nant pustules. An aqueous solution of methylene blue (Loeffler's solution) 
stains it very well. 

Pharyngeal exudate is frequently examined for evidence of diphtheria 
and other diseases of this region. A complete investigation of this exudate 
demands three procedures: 1. Morphological examination of the exudate. 
2. Biological examination. 8. Test by inoculation. 

1. Morphologically the Klebs-Loeffler bacillus, or the Bacillus diph- 
therioB, is usually distinct. When only a very few bacilli are found and 
many cocci, we must resort to the biological test. 

2. A smear from the throat is gently rubbed over the surface of a blood 
serum culture medium, and the latter kept in a thermostat for from twelve 
to twenty-four hours. Under these conditions the Klebs-Loeffler bacillus 
grows rapidly, outstripping other microorganisms found in the mouth and 
throat. After twenty-four hours the colony has a sharply outlined, slightly 
elevated, granular, dry, creamy yellow or grayish growth. Some of this 
growth is then to be transferred to a slide by the aid of a sterilized plati- 
num wire, mixed thoroughly with a little water, spread into a thin film, 
and then dried, fixed, and stained. The preparation should be examined 
under the microscope with a yV oil immersion lens. The methylene blue 
solution: Saturated alcoholic solution of methylene blue, 30 parts; Aqueous 
solution of potassium hydrate (1 in 10,000), 100 parts. Stain for about one 
minute. 

N. B. — Before a morphological diagnosis can positively be made of B. 
Diphtherise, it is essential that certain conditions be fulfilled, viz.: 

1. Smear is from naso-pharyngeal or laryngeal exudate. 

2. Culture must be growth not older than 16 hours at 37° C. 

3. Growth has been made in Loeffler's blood serum. 

4. Morphological characteristics must be typical. 

3. In a case of mild pharyngitis, even with the above described tests, 
we cannot always diagnosticate diphtheria without inoculation. Method 
of inoculation: One half a cubic centimetre of a forty-eight hours' broth 
culture of the bacillus to be tested is injected subcutaneously into a guinea 
pig. Cultures of ordinary virulence will cause the death of the animal 
in thirty-six hours. If of slight virulence, the culture may require from 
three to four days to cause death, or it may fail to kill. Non-virulent 
cultures produce no distinct effect upon the animal. 



40 LABORATORY AIDS TO CLINICAL DIAGNOSIS 

STAINS 
Carbol Fuchsin Solution: 

Fuchsin (basic, not acid), 1.8 parts; 

Carbolic acid, 5.0 parts; 

Alcohol, 10.0 parts ; 

Distilled water, 100 .0 parts. 

Acid Alcohol Solution: 

Absolute alcohol, 290 .0 parts; 

Concentrated hydrochloric acid, 10 .0 parts. 

Methylene Blue Solution: 

Methylene blue, 1.0 parts; 

Sodium chloride, 0.6 parts; 

Distilled water, 100 .0 parts. 

BREAST MILKi 

In mother's milk we may wish to estimate the amount of fat and pro- 
teids and to determine the specific gravity. By means of any small hy- 
drometer, graduated from 1.010 to 1.040, we may determine the specific 
gravity of milk that has been expressed by hand or by means of the breast 
pump. The average is 1.031. 

To approximately determine the percentage of fat, a small calibre test 
tube, graduated from 1 to 100, is filled to the 100 mark with milk pumped 
from the breast. An indefinite amount of ether is added, and the contents 
are thoroughly shaken. On standing for half a day the liquid separates 
into two layers, ether and fat, and milk minus fat. If, for example, the 
point of demarcation between the two layers is at 97, there is 3 per cent 
of fat. 

To estimate the proteids, decant the ether and fat from the tube and 
precipitate the casein contained in the skim milk by the addition of acetic 
acid or rennet. The curd formed is then collected on a filter (the weight 
of the filter being known), and the salts, etc., are washed out with water. 
The filter and curd are dried in an oven and weighed together. Deduct 
the weight of the filter from the total weight, and the remainder will give 
the weight of the curd. For example, if in a test tube graduated in grammes 
the weight of the curd is found to be 2 . grammes, the percentage of pro- 
teid is 2 approximately, if the quantity examined has been 100 grammes. 

CULTURES 

From time to time it is of advantage to be better acquainted with 
the microorganism than is possible from microscopical examination of pus 
or fluids as they are taken from different parts of the body. The study 
of bacteriology has demonstrated that a given microorganism seems to 
thrive better in one medium than in another. This knowledge enables 
us to obtain an early and abundant growth. 

The bacteria which it is most often desirable to study by growth in 
culture media are: The Klebs-Loeffler bacillus of diphtheria, the colon 

' Holt has devised an inexpensive milk tester. 



CULTURES 41 

bacillus, the streptococcus, the staphylococcus, the Bacillus pyocyaneus, 
the pneumococcus, the gonococcus. 

Klebs-Loeffler Bacillus. — The Klebs-Loeffler bacillus grows best and 
most rapidly on blood serum. Its colonies are large, round, elongated, 
grayish, white, or yellowish, with the centre more opaque than the slightly 
irregular periphery. The surface of the colony is at first moist, but after 
a day or two becomes rather dry in appearance. 

Rapid Bacteriological Diagnosis of Diphtheria. — Loeffler sugar blood 
serum. A sterile cotton swab is drawn over the exudate in the pharynx 
or on the tonsil, and smeared over the surface of a blood serum culture 
medium. After the test tube is inoculated, it is placed in an incubator, 
which has previously been heated to between 37° and 38° C. (98.6° and 
99° F.). A small water oven, such as is in use in laboratories, just large 
enough for the test tube, is very good. It can first be heated to 37° or 
38° C. with a Bunsen burner and kept at that temperature by means of an 
ordinary small kerosene lamp. The tube is left in the oven for two and a 
half to three hours, and then the growth is removed by means of a platinum 
wire loop. The smear is made as in staining for examination under the 
microscope. 

Colon Bacillus. — The colon bacillus seems to grow most characteristically 
upon gelatin, and grows both with and without oxygen, on the surface 
and within the gelatin. On the surface the colonies appear as small, dry, 
irregular, flat, blue-white points that are commonly somewhat serrated 
at the margin. They are a trifle more dense at the centre than at the 
periphery, and are often marked at or near the middle by an oval or round 
nucleuslike mass. Examined by a low power lens, they are at first seen 
in the depths of the gelatin as finely granular, very pale greenish yellow, 
round, oval, and lozengelike colonies. Later they appear denser, darker, 
and more markedly granular. 

Streptococcus. — The streptococcus appears on gelatin plates in from 
forty-eight to seventy-two hours as very small, flat, round, bluish-white 
and opalescent points. In gelatin stab cultures it grows along the entire 
needle track as a finely granular line, the granules representing minute 
colonies of the organism. 

Staphylococcus. — The staphylococcus aureus, grown on agar-agar, 
usually appears to the naked eye as round, moist, glistening, yellow or 
orange colored colonies. When situated in the depths of the medium, 
they are commonly seen to be lozenge-shaped or whetstone-shaped, often 
as irregular stars with blue points, and again as dense, irregularly lobulated 
masses. After thirty-six to forty-eight hours, a pure stab culture in gelatin 
produces liquefaction along the line of the needle track. As the culture 
becomes older, liquefaction increases until all the gelatin in the tube be- 
comes liquid. 

Bacillus pyocyaneus, the bacillus of green pus, blue pus, or blue-green 
pus, as it is commonly called, when grown on gelatin plates, develops a 
round, not sharply defined mass, which at first usually presents a peripheral 
fringe of delicate filaments. As growth progresses, liquefaction occurs, 
and as the latter advances, the central mass of the colony sinks into the 
liquefied depression, while laterally the colony extends. 



42 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



A stab culture in gelatin is accompanied with liquefaction, and diffusion 
of a bright green color takes place throughout the unliquefied gelatin. All 
the gelatin finally becomes liquid, and the green color is confined to the 
superficial layer in contact with the air. 

Gonococcus. — The gonococcus grows well on blood serum mixed with 
agar. The gonorrhoeal pus should be mixed with uncoagulated serum and 
the mixture added to one or two parts of melted agar at about 40° to 50° C. 
This mixture is allowed to solidify in an oblique position in the tube. The 
late method is the one commonly employed. Superficial colonies are 
described as having a compact centre with a very delicate, transparent, 
finely granular zone with projections like peninsulas on a map. Deeper 
colonies are solid, clumpy, with a sharp, regular contour. 

Pneumococcus. — The pneumococcus seems to grow best at rather 
higher temperatures than that of the room (at about 78° to 79° F.) and 

upon a strongly alkaline medium 
or blood serum. The colonies ap- 
pear small, distinct, round, and 
transparent, resembling dew drops. 

BLOOD 

Examination. — For the exami- 
nation of the blood, the apparatus 
necessary includes : 

A haemoglobinometer (Gowers's 
or Fleischl). 

A Thoma-Zeiss counting ap- 
paratus. 

Microscope slides, cover glasses, 
etc. 

Gowers's Method. — To estimate 
the relative amount of haemoglobin 
in a given case, the tip of the finger or lobe of the ear is punctured after 
having been thoroughly cleansed with alcohol or ether. The blood is drawn 
by suction into the pipette up to the 20 cm. mark. Any trace of blood that 
may adhere to the outer surface of the pipette is carefully wiped off and 
the contents are at once mixed with a few drops of distilled water previ- 
ously placed in the graduated tube so as to guard against the blood coag- 
ulating on its walls. Clean out the pipette as carefully as possible, so 
that every particle of blood is washed into the tube. Hold the two tubes 
side by side directly against the light, and add distilled water, drop by drop, 
until the shade of color is the same in each tube. The division on the scale 
thus reached will express the relative percentage of haemoglobin. The 
Tallquist hcemoglohin scale greatly simplifies the estimation of hajmoglobin. 
A drop of blood is allowed to soak into a prepared blotting paper, which 
is sold as leaves of a small book. While it is still moist, compare its color 
with a color scale representing the different percentages of haemoglobin. 

Counting the Cells. — Counting of the blood cells is a trying and tedious 
procedure, but is of great value in many cases. The apparatus consists 
of a slide (a), upon which is arranged a chamber (b) the floor of which is 




Fig. 9. — H^moglobinometer. 



BLOOD EXAMINATION 



43 



marked most accurately into little squares (c). The chamber is exactly 
0.1 mm. in depth, and each of the sixteen small squares contains tuW 
c.mm. A capillary pipette with a bulb on the up- 
per third has graduations marked . 1 mg. to 1 . 0, 
while above the bulb it is marked 101. 

The tip of the finger or lobe of the ear is 
punctured after thoroughly cleansing the parts and 
apparatus. The finger should be cleaned with soap 
and water, then with alcohol and ether. The exud- 
ing blood is drawn into the capillary tube to the 
mark . 5 or 1 . 0, according to the degree of dilution 
desired, care being taken to exert very slight press- 
ure upon the finger. Then, after wiping the tip 
of the pipette, sufficient 6 per cent salt solution is 
drawn into the pipette to fill the bulb and reach 
the 101 mark. Mix thoroughly by shaking. Blow 
out the contents of the capillary tube below the 
bulb, as they are probably only salt solution, and 
then blow a drop of the mixture upon the counting 
chamber, immediately covering it with a cover 
glass (/), bubbles of air being carefully expelled. 
After allowing the corpuscles three to five minutes 
to settle, they are then counted, going over at least 
one whole field (200 squares) or, if special accuracy 
is desired, two whole fields (400 squares) when 
counting the red cells and 400 squares when count- 
ing the leucocytes. 

In order to obtain the number of red corpuscles 
contained in one c.mm. of blood, the total number 
noted is divided by the number of small squares 
counted, the result being the average number in 
one small square. Example: Suppose 1,200 red 
corpuscles were counted in 400 small squares, the 

average number contained in one, that is ^roVff c.mm., of diluted blood 
would be 3, — corresponding to 12,000 corpuscles for each cubic millimetre. 
If the blood is diluted 200 times, multiplying by 200 would give 2,400,000 
in one c.mm. of the undiluted blood. Drs. Einhorn and Laporte have 



i£ 



l5 



I 



V 



Fig. 



10. — Thoma-Zeiss 
Pipettes. 



0.100 mm. 
4 00 5"'- 




Fig. 11. — Counting Slide (plan). 



44 LABORATORY AIDS TO CLINICAL DIAGNOSIS 

invenfced a rapid blood counting method by means of a blood counting 
diaphragm manufactured by Eimer & Amend, of New York City. 

In counting leucocytes, it is better to have a special pipette, allowing 
a dilution of from 1 to 10 or 1 to 20. For diluting, a . 3 or . 5 per cent 
solution of acetic acid is used, which destroys the red blood cells. The 
same method of mixing, preparing the drop on the slide, and counting 
is done as for red cells. Red cells are normally 5,000,000 per c.mm.; 
leucocytes, from 5,000 to 8,000. 

Significance of Hyperleucocytosis 

Physiological. — In children, Hayem says, 18,000 are found in the first 
eighty hours of life, 9,000 during the first month, and 8,000 up to the fourth 
year. They are also found during digestion, immediately after a cold 
bath, and during the last five months of pregnancy. 

Pathological. — " Leucaemia " is not usually classed under "hyperleucocy- 
tosis." The latter term is generally employed to indicate an increase in 
the multinuclears in transitory conditions. Leucaemia is a permanent 
condition. In leucaemia the proportion of white cells may be 1 to 10 or 1 
to 5, or 1 to 1 of the red cells, while normally it is about 1 to 8,000 or 1 to 
10,000. 

In acute inflammatory diseases, in general the degree of hyperleucocy- 
tosis is directly proportionate to the degree of local reaction. For example, 
in typhoid fever the local reaction is slight, but if there is a complicating 
pneumonia or pleurisy in which the local reaction is great, a correspond- 
ingly marked hyperleucocytosis will be found. 

In pneumonia the degree of hyperleucocytosis may serve as a direct 
index of the amount of lung tissue involved, disappearing during the crisis 
or even a few hours before it sets in. In phthisis it occurs apparently only 
when the disease has led to the formation of cavities (secondary or mixed 
infection). In the cachexia of malignant disease it is often of great intensity, 
and it is said to be of value in the differential diagnosis between malignant 
and benign disease of the stomach. 

PREPARATION OF BLOOD SLIDES 

Preparation of blood slides, for the examination of the blood cells and for 
Plasmodium Malarice, After scrubbing the finger tip or lobe of the ear 
with soap and water, and then with alcohol and ether (it often suffices to 
rub well with ether alone), a blood drop is drawn with a sterile lance or 
needle. Then pass the end of a slide, cleaned with ether and alcohol, through 
the drop and smear over the properly cleaned slide. It must be most care- 
fully done, and no grease must be on the slide. 

It is first stained with Jenner's alcoholic solution of eosin, or methy- 
lene blue 5 to 10 minutes, the slide being examined from time to time to 
see if the depth of stain is sufficient. When sufficiently stained, it is 
washed with water, and dried, and is then ready for examination under 
the microscope. A 1-12 oil immersion lens should always be used when 
possible. 



DISEASES REQUIRING BLOOD EXAMINATION 45 



DISEASES REQUIRING BLOOD EXAMINATION 

Chlorosis. — In chlorosis we observe: Diminution of haemoglobin, 60 per 
cent to 20 percent; low haemoglobin index = ratio between the percentage 
of haemoglobin and the number of red cells; the number of red cells may 
be nearly normal, rarely less than 2,000,000; the red cells show a large 

C!over glass. 

■B 




Ruled disk. Moat. 

Fig. 12.^Blood Counting Slide (elevation). 

unstained central area, indicating a loss of haemoglobin ; in severe cases the 
shape and size of the red cells may be changed, and nucleated red blood cells, 
called normoblasts, are often seen; the leucocytes are usually but little 
affected. There may be a slight increase in all varieties. 

Secondary Anaemia. — The blood is impoverished in all cases attended 
with malnutrition, toxaemia, or haemorrhage. To make a diagnosis of this 
form of anaemia, we should first recognize the presence of a primary disease, 
such as carcinoma, ulcer of the stomach, nephritis, rhachitis, malaria, syph- 
ilis, etc., and then note in the blood examination: The haemoglobin may be 
as low as 15 per cent; the red cells as few as 1,000,000; the haemoglobin index 
not so low as in chlorosis; a moderate number of multinuclear leucocytes, 
the presence of which often characterizes the blood of secondary anaemia. 

Pernicious Anaemia is a disease of the blood-producing organs tending 
to a fatal issue. On examination we find: the haemoglobin usually below 
25 per cent; the red cells always fewer than 2,000,000, 
and frequently below 1,000,000; the haemoglobin index 
usually increased, as there is an increase of haemoglobin 
in the remaining red cells; characteristic changes in the 
size and shape of the red cells, megalocytes; mis- 
shapen and deformed red cells of all sizes — poikilocy tes ; 
the haemoglobin in many cells changed so as to make it 
stain brownish with eosin — polychromatophilia; nucle- ^^^- 13. — Blood 
ated red cells of large size, called megaloblasts, their ountin 

° ' . ° f 1 PHRAGM. Actual 

presence in large numbers being pathognomonic of the size (Dfs. Ein- 
disease; microblasts, staining brownish with eosin; red horn and Laporte). 
cells not collecting in rouleaux; the plasma of the blood 
perhaps staining with eosin, indicative of haemoglobin solution in the plasma 
— haemoglobinaemia ; the leucocytes usually diminished, those remaining 
being principally of the uninuclear variety. 

Splenic Anaemia is classed as a disease of the spleen. It is usual to 
find a reduced number of red blood cells, the haemoglobin is relatively low, 
and the leucocytes are reduced in number. The changes are associated 
with enlargement of the spleen. 




46 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



Hodgkin's Disease has those changes in the blood of the microcytic 
form of pernicious anaemia. 

Secondary Pernicious Anaemia. — The severe grades of secondary anaemia 
most frequently result from malaria, syphilis, carcinoma, nephritis, and 
tuberculosis. On examination we find : 

The red cells may show an excess of haemoglobin (megalocytic type), 
unless, as is usual in the very acute cases, they are normal or reduced in 
size and show a deficiency of haemoglobin (microcytic type) ; megaloblasts 
are usually absent; a persistent multinuclear leucocytosis usually serves 
to distinguish the blood of secondary from that of primary pernicious 
anaemia. 

Leucaemia. — A disease of the blood and blood-producing organs charac- 
terized by progressive anaemia, increase in the white cells of the blood, 




Fig. 14. — Counting Blood Cells. 



and certain changes in the viscera. In many respects it resembles a tumor 
formation in a fluid tissue. 

Myelogenous Leucaemia. — The chief feature of the blood in this form 
is the presence of a large number of myelocytes and multinuclear leucocytes. 

There are three varieties of myelocytes: 1. Ehrlich's myelocyte, of the 
same size as the multinuclear leucocytes, with a single pale central nucleus 
and neutrophile granules. This form is seen in secondary anaemias, but 
is abundant in myelogenous leucaemia. 2. Cornil's myelocyte, a very 
large cell with a single pale eccentric nucleus and neutrophile granules. 
This cell is seen almost exclusively in this disease. 3. The eosinophile 
myelocyte, a uninuclear leucocyte with unusually large and darkly staining 
eosinophile granules. This cell has been observed only in this disease. 



DISEASES REQUIRING BLOOD EXAMINATION 47 

Mast cells are seen in considerable numbers only in chronic myelogenous 
leucaemia. 

Lymphatic Leucaemia. — In this form the increase is of the small and 
medium sized lymphocytes, while multinuclear leucocytes are scanty and 
myelocytes and mast cells are absent. 

Malarial Parasites. — The Plasmodium of malaria has its life process in 
the red blood cell, and it discharges the embryo into the plasma, this dis- 
charge being simultaneous with the chill. There are three forms: 

1. The tertian, which gives a chill every forty-eight hours. 2. The 
quartan, every seventy-two hours. These two forms are very much alike, 
and can readily be demonstrated under the microscope. 3. The cestivo- 
autumnal type usually gives paroxysms every seven days and is undisturbed 
by quinine, except the chill, which is arrested. All these forms can be 
studied when they are alive in fresh blood or in stained specimens. 

To study a fresh specimen of blood, the fingers, slide, and needle should 
be scrupulously clean and aseptic. A small drop of blood is placed upon 
the slide and a cover glass placed over it, when it is ready for study. The 
parasite is best studied in diagrams, where the diiferent forms, indicating 
its degree of development, can be compared. Probably the best time to 
take a specimen is from twelve to eighteen hours after a chill, and the 
most characteristic feature is the granules of dark brown, nearly black 
pigment. 

Widal Reaction. — This reaction depends upon the observation of Pfeiffer, 
that the action of the blood serum of a typhoid fever patient upon a minute 
quantity of a pure typhoid culture causes a loss of motility of the individual 
germs and also their so-called "clumping," an agglutination of the bacilli. 
It is found distinctly upon the fourth to the seventh day in 70 per cent of 
cases; upon the eighth to the tenth day in 80 per cent of cases; upon the 
third to the fourth week in 90 per cent of cases. It is absent throughout 
the disease in from 5 to 10 per cent of the cases. We also find all degrees 
of reaction. Sometimes there is an instantaneous loss of motility, some- 
times in fifteen minutes, and sometimes there is only a partial loss of 
motion. Many other diseases give this partial reaction, only in low dilutions. 

If the dilution of the blood is 1-10, and the reaction is present, the 
diagnosis is particularly certain; if 1-20, the diagnosis is absolutely certain. 
Absence of the reaction is not an assurance that the disease is not typhoid, 
but such cases are usually mild. The reaction is often slight or absent 
in cases ending fatally. In cases in which the Widal test is negative, 
infection with bacilli of the paratyphoid group should be suspected. 

Procedure: A drop of blood from the patient is dried upon a slide just 
as it exudes from the finger punctured after due antiseptic precautions. 
Then dilute 1-10 times or 1-20 times with sterile water. Place on a cover 
glass by means of a platinum needle a drop of a twenty-four hour bouillon 
culture of the typhoid bacillus, or a pigment of an agar culture growth. 
Mix it with the diluted blood serum and invert it over the hollow of a slide 
made for the " hanging drop." In order to prevent all possibility of spread- 
ing any infection and getting a pure culture, the platinum needle should be 
held in the flame of a Bunsen burner or alcohol lamp both before and after 
each use. It is also a good plan to make a narrow ring of vaseline around 



48 LABORATORY AIDS TO CLINICAL DIAGNOSIS 

the hollow in the slide for the hanging drop and to place the cover glass 
upon it to prevent slipping. The specimen is now ready for study. The 
Widal reaction seldom appears before the second week of the fever, and 
may be delayed even until convalescence. In a small number of cases it 
may never be present (paratyphoid?). In others it may be intermittent. 
As it seldom appears before the beginning of the second week, the test is of 
little value up to this time. As it often appears late in the disease, and 
as it may be present only intermittently, typhoid fever cannot be ex- 
cluded by a single, or even by repeated negative tests. Repeated negative 
tests, however, are very strong evidence against the existence of typhoid. 
A positive reaction, if the patient has not previously had typhoid, is almost 
certain proof of typhoid. A negative reaction, followed by a positive re- 
action in a dilution of 1-50, is absolute proof of typhoid. The Widal 
reaction can also be determined by using serum instead of blood. 

The reaction has been found by Scholtz as long as fifteen years after 
typhoid, and by Kasel and Mann as long as twenty-one years after recovery. 
If this were trvie, it would explain our practical immunity from a second 
attack. Cases of enteric fever presenting all clinical evidence of typhoid 
fever, but without the Widal reaction, are said to be due to a paratyphoid 
bacillus, and are termed " paratyphoid," for which a special test has been 
devised. 

A macroscopic Widal reaction is obtained by taking up serum in a grad- 
uated pipette and diluting it to the desired degree (usually 1 in 40) with a 
live or dead (formalized) typhoid culture. The mixture is placed in a 
small test tube and allowed to stand. A time limit of three hours is set. 
A positive reaction is obtained when the bacilli are agglutinated and falling 
to bottom of tube leave a clear supernatant fluid. 

Filaria. — Occasionally it is desired to examine the blood for the parasite 
causing elephantiasis, the Filaria sanguinis hominis. A peculiarity of the 
parasite is that it can be found in the blood only when the patient is at rest. 
So for one occupied during the day the blood specimen to be examined is 
taken at night, and vice versa. It can be found at any time. 

lodophilia. — This is a blood test first described by Dr. Theodore Dunham, 
of New York, who says: "I have ventured to coin this word to designate 
a reaction which occurs in the blood under certain pathological conditions. 
I bring this subject before you because this reaction has been a definite 
help to me in diagnosis, and I feel that it deserves a more extended use than 
it has yet received. The cases in which it gives aid are those of doubtful 
suppuration and doubtful pneumonia. We are not infrequently confronted 
with cases of appendicitis where an additional aid to the early recognition 
of pus would be of the greatest value; and there are other cases of deep- 
seated trouble with doubtful physical signs where an additional means of 
throwing light on the presence or absence of pus would be a great help. 
Pneumonia is often difficult of recognition during the first few days after 
the onset. An additional aid in diagnosing it during this stage would be 
of real value. 

" Let me say a word about the technique of the reaction and then speak 
of its clinical bearings. The technique is very simple. It consists in the 
staining and examination of a spontaneously dried blood smear. The 



DISEASES REQUIRING BLOOD EXAMINATION 49 

smear need not be stained at once, but will be good for use several weeks 
at least after making. It is thus possible to make the smear at the bedside 
and send it to the laboratory for staining and examination. Only one 
solution is required, and this is made up as follows: Three parts of potassium 
iodide are dissolved in one hundred parts of water. In this is dissolved one 
part of iodine. The resulting solution is thickened to a syrupy consistence 
by the addition of lumps of gum arabic and occasional shaking until they 
are dissolved. The blood smear is mounted in a drop of this syrup, and 
a bit of filter paper placed at an edge of the cover glass to absorb the excess 
of fluid. The specimen is then ready for examination by an oil immersion 
lens. When blood is treated in this way the lymphocytes and the eosino- 
philes are not affected by the stain. 

"It is apparently always present in progressive suppurations and in 
progressive pneumonias. It may also occur in a few other diseases, but 
they are fortunately easy of recognition in other ways and not to be con- 
founded with abscess or pneumonia. The intensity of the reaction is said 
by other observers to be closely related to the intensity of the process, 
and I have found this to be true in the cases I have examined. Small 
abscesses will, however, if the process be active, give a distinct reaction. 
In cases of so-called tuberculous abscess the reaction is absent. Abscesses 
caused by the germs of acute suppuration, but which are well walled off 
and have assumed an indolent course, rarely give the reaction. If, however, 
the process lights up again, the iodine reaction is said to return. Gold- 
berger and Weiss, from an examination of a considerable number of other 
diseases as well as of abscess, reach the conclusion that a distinct intracellular 
iodine reaction, even if made out in only a few leucocytes, warrants the 
conclusion that there is present a progressive suppurative process. In 
reaching this conclusion, of course the few other lesions which give rise 
to iodophilia must be excluded. 

" Let me now speak of the relation of iodophilia to pneumonia. Other 
observers say that the iodine reaction occurs constantly in pneumonia. 
I have found this to be true in the cases which I have examined. The 
reaction would not be of great value in pneumonia if it were present only 
when consolidation was so far advanced as to give a typical picture of the 
disease, for then the usual diagnostic signs are sufficient. But in two cases 
where I have examined the blood at an early stage, before physical or other 
signs were specially suggestive of pneumonia, I found a well marked iodo- 
philia. This early appearance of iodophilia in pneumonia I have not seen 
referred to by others, and know of it only from the two instances where I 
looked for it. If it proves to be uniformly present soon after the onset, 
iodophilia will be one of the earliest diagnostic signs of pneumonia. 

"As I have already said, certain diseases must be eliminated from the 
diagnosis before one concludes that iodophilia implies the presence of pus 
or pneumonia. Hofbauer, at Neusser's clinic in Vienna, found that iodo- 
philia occurred in certain grave blood diseases. In eighteen cases of chlorosis 
he failed to find it. In eighteen cases of secondary anaemia he found it 
in two, but one of these was complicated by pyothorax and the other by 
gonorrhoeal annexa, and its presence was probably due to these complica- 
tions. But in really grave anaemia, as that associated with cancer of the 
5 



50 



LABORATORY AIDS TO CLINICAL DIAGNOSIS 



stomach, severe chronic intoxications, etc., where the blood picture ap- 
proached that of pernicious anaemia, he regularly found a greater or less 
number of iodophile leucocytes in the seven such cases he examined. In 
advanced pernicious anaemia and in leucaemia he also found it. I found it 
very marked in the one case of leucaemia which I have examined in this way. 
"As iodophilia is a natural accompaniment of these diseases, in them 
its presence throws no light on the existence of pus or pneumonia. During 
an examination with the iodine test these grave blood diseases would surely 




Fig. 15. — Making a Blood Sme.\r on a Slide. (Wood.) 

be recognized. With their elimination, the finding of iodophilia points to 
acute suppuration or to pneumonia." 



TISSUE SPECIMENS 

Preparation for Microscopical Examination. — The specimen is cut into a 
cube of about one and a half centimetres in each dimension. It is hardened 
by running it through the following solutions the specified length of time: 

4 per cent formalin, 24 hours. 



80 

90 

100 

100 

3 

6 



alcohol, 24 

'' 24 

" 24 

" and ether, each 24 

celloidin, 24 

24 



(better one week). 



I 



CALCULI 51 

Block and leave in 70 per cent alcohol for twenty-four hours. Cut 
sections on a microtome. Stain in haematoxylin for from tHree to five 
minutes (Delafield's preparation diluted three times); H2O + a few drops 
of ammonia, for a few seconds; H2O for half an hour; alcoholic solution 
of eosin, for 1 to 2 minutes; alcohol, 90 per cent, for a few seconds; alcohol, 
100 per cent, for a few seconds. Then place in oil of origanum, bergamot, 
or cloves until they are ready to mount in Canada balsam. 



ANALYSIS OF DRINKING WATER 

Chemical Examination. Tests. — Test for total solids; hardness; 
chlorine; free and albuminoid ammonia; nitrates; nitrites. 

The first three tests are a measure of the mineral constituents, while 
the last three show the organic contents of the water. If the history of 
the water is known, an excess of chlorine may point to sewage contami- 
nation. The free and albuminoid ammonia indicate animal and plant 
pollution. A large amount of nitrates usually shows that the water has 
been purified by oxidation. Nitrites should never be present to any 
amount in surface water. 

Bacteriological Examination. — We wish to know if the water has been 
polluted by sewage; if there are bacteria, whence they are probably de- 
rived. The finding of the colon bacillus accompanied by the germs of 
putrefaction, if at the same time the chemical analysis shows an excess 
of nitrites or albuminoid ammonia, is sufficient reason to pronounce 
water unfit for drinking. The test for the colon bacillus and typhoid 
bacillus, with accompanying putrefactive bacteria, is accomplished by 
means of cultures and gross and microscopical examination. 



CALCULI 

. Renal Calculi may be composed of uric acid, calcium salts, or phosphates. 
The nucleus is formed by a deposit from an excess of the crystalline particles 
of the urine. These particles become adherent through a bit of mucus or 
clot of blood, and fresh deposits are gradually added to the nucleus. The 
shape is usually irregular, conforming to the shape of the pelvis of the kidney 
and its branching calices. 

Ureteral Calculi. — A stone from the kidney may descend into the ureter, 
and become lodged there. 

Vesical Calculi have for nuclei uric acid crystals, a mass of inspissated 
mucus, or some small foreign body. They may be primarily formed in the 
kidney. We usually find them to be composed of urates and uric acid, 
phosphatic salts, or oxalate of lime. Rarely one is found composed of 
cystin. The framework which holds the crystals together is albuminous, 
and thus it is essential to stone formation, to have an abnormal urine, 
such as one containing inflammatory products, mucus, or blood, and one 
at the same time rich in salts. A stone may gradually increase in size so 
that in time it is possible for one to fill the bladder. Occasionally elonga- 



52 LABORATORY AIDS TO CLINICAL DIAGNOSIS 

tions extending into a ureter, the urethra, or a vesical pouch may form. 
One may begin in the prostatic sinus, and enlarge backward into the bladder 
or forward into the urethra. Vesical calculi may be multiple. 

Urethral Calculi -are rare, but it is possible to have a vesical or renal 
calculus lodge in the urethra behind a stricture. 

Prostatic Calculi with nuclei of organic matter (prostatic secretion), 
upon which salts of lime may be deposited, may be found in the prostatic 
ducts or scattered throughout the gland. 

Calculi with hair attached point to the presence of a dermoid cyst. 

Gall Stones usually form in the gall bladder, but occasionally in the ducts 
or biliary passages of the liver. Cholesterin and bile pigments form the 
basis, but there must be some obstruction of the passages and inflammation 
of the mucous membrane to allow of their precipitation from stagnant 
bile. There may be a single stone or many, and the size varies from that 
of a small gravel to two to three inches in diameter. 

Pancreatic Calculus. — Rarely a stone may form in the pancreatic duct. 

Salivary Calculus. — Phosphate and carbonate of calcium may be de- 
posited in a salivary gland or duct, forming a stone from the size of a grain 
to one of the size of a walnut. 

Rhinoliths always have for a basis some foreign body which has been 
put into the nose or a mass of inspissated mucus. The irritation which 
is set up from their presence causes a precipitation of solids about this 
niicleus, 

CYTODIAGNOSIS, CYTOLYSIS, ETC. 

Cell Diagnosis. — By this term is meant diagnosis by means of the 
chemical and microscopical characteristics of the effusions into the serous 
cavities of the body. 

If we have such a fluid to examine, we note its appearance, color, and 
density, and the presence of fibrin; we analyze it for its chemical composi- 
tion; we examine it with the spectroscope; determine its freezing point 
(cryoscopy), its hemolytic property, its agglutinating properties, and its 
toxicity. We look for bacteria, make cultures, and inoculate animals. 
Microscopically, we note the kind of cell contents. 

In a pleuritic fluid w^e try to determine if it is from: 1. A tuberculous 
process : a. Primary; 6. Secondary to a tuberculosis elsewhere in the body; 
c. Tuberculous hydropneumothorax. 2. Non-tuberculous process : a. Sep- 
tic — Pneumococcus, streptococcus, bacillus of Eberth, etc.; b. Aseptic — 
Mechanical (cardiac or renal), leucsemic, cancerous, from abscess of the 
liver, syphilis, rheumatism, diphtheria. 

If in the cellular contents we find that the lymphocytes predominate, it 
points to a tuberculous origin; if the multinuclear leucocytes predominate, 
it points to a pneumococcus or streptococcus origin. Simple endothelial 
cells are found in a passive effusion, and cancer cells in some stages of a 
cancerous effusion. It has been found that there are peculiar cell reactions 
to staining agents, so that we can determine whether the cells come from a 
primary or secondary tumor. If there are many tissue cells in a pleuritic 
fluid, we have good reason to suspect the presence of a neoplasm. 

In a peritoneal effusion, we try to determine if it is a mechanical ascites, 



CYTODIAGNOSIS, CYTOLYSIS, HEMOLYSIS, ETC. 53 

ascites due to a neoplasm, acute peritonitis, tuberculous peritonitis, or 
fluid from an ovarian cyst. 

In a pericardial effusion, we try to find whether it is tuberculous or renal. 

In an articular effusion, it may be due to tuberculous hydrarthrosis, 
tuberculous arthritis, rheumatic arthritis, gonorrhoeal arthritis, traumatic 
hydrarthrosis, tabetic arthropathy, or synovitis of simple origin. 

In effusions into the tunica vaginalis, it may be from tuberculous hy- 
drocele, gonorrhoeal orchitis, typhoid orchitis, traumatic hydrocele, essen- 
tial hydrocele, cyst of the cord. 

We also examine the fluid from skin eruptions as seen in bullae, vesicles, 
and pustules; as herpes, pustules of variola; blister from burning, acci- 
dental or artificial. 

In particular, the examination of the cerebrospinal fluid, obtained by 
lumbar puncture, has been of aid in diagnosis. In the absence of cellular 
elements, we judge that there is no bacterial cause, that the symptoms are 
due to a polyneuritis or a poliamyelitis. When the meninges are affected, 
there are cell elements found. In the beginning of the paralytic period, 
due to a meningitis, when the inflammation is localized, we find a lymphocy- 
tosis, but when the inflammation is extensive, we find a multinuclear 
leucocytosis. 

Cytodiagnosis of the cerebrospinal fluid seems likely occasionally to 
be of great help in distinguishing doubtful cases of paresis and tabes in the 
early stage. " In spinal syphilis, as shown in cases of syphilitic meningo- 
myelitis, as Erb's spinal paralysis, there is an increase in the cell count, 
and if trauma can be excluded, the presence of specific infection may be 
inferred." The activity of the process may be judged also. ''If any 
active inflammatory change be going on, polynuclear leucocytes will pre- 
dominate, while in ordinary conditions of specific infection, only mono- 
nuclears are present, with a proportion of polynuclears of not over 5 per 
cent." 

Cytodiagnosis of the cerebrospinal fluid promises to aid us in the diag- 
nosis of tuberculous meningitis, pneumococcus meningitis, meningococcus 
meningitis, streptococcus meningitis, tabes, general paralysis, syphilis of 
the cerebrospinal system, meningo-myelitis, cerebral lesions, sclerose en 
plaques, tetanus, syringomyelia, affections of the ^peripheral nerves, chorea, 
neuroses epilepsy, mental affections, leucaemia. 

CYTOLYSIS, HAEMOLYSIS, ETC. 

Immunity and serum therapy have received a great deal of study during 
the last few years, and an immense amount of new knowledge has been 
obtained which opens great possibilities. With the exception of the mar- 
velous results from diphtheria and tetanus antitoxine, we have not yet 
been able to apply this knowledge with any great success. When we apply 
the " side chain hypothesis " of Ehrlich, we can formulate the process which 
goes on in the body when one acquires immunity. Lack of space prevents 
a complete consideration of this subject, but a few definitions may aid in 
the understanding of the voluminous literature which has been and is 
appearing. 



64 LABORATORY AIDS TO CLINICAL DIAGNOSIS 

Antitoxins. — By antitoxins we mean substances generated in the fluids 
of the body by stimulation of the cells by irritation from bacterial or 
other toxins. This substance neutralizes the toxin and thus achieves an 
active immunity. If this toxic and antitoxic process takes place first in 
an animal which becomes immune, and the blood serum of this animal is 
injected into the body of a person suffering from the effects of the same 
toxin, we establish in this person a passive immunity. 

Cytolysis is a destruction of cells by some toxic process. 

Haemolysis is a disintegration and destruction of the blood. This takes 
place through the formation of an hcemolysin, a substance formed by bacterial 
or other action and capable of destroying the red corpuscles. An haemoly- 
sin is formed in the body of an animal into which red blood corpuscles of 
another animal have been introduced. This hsemolysin is capable of dis- 
solving the red blood corpuscles of the animal from which the blood was 
derived. 

Agglutinins are substances formed in the blood as a result of infection 
and capable of causing agglutination or coherence of the bacteria that pro- 
duced the infection. 

Precipitins are formed in a similar manner. If blood serum or exudate 
containing globulin from one animal is introduced into another animal 
of a different species to become adapted, the addition of a little of the 
blood serum of the adapted animal to a dilution of the fluid injected will 
form a precipitate. This reaction is supposed to lead to the identification 
of human blood, and it is hoped, as also it is hoped in these other processes, 
that important features in specific therapy will be discovered. 

CRYOSCOPY 

This word is used to designate the effort to determine the functional 
activity of the kidney by comparing the freezing point of the urine obtained 
by ureteral catheterism with that from kidneys known to be normal, and 
with the freezing point of the blood of the patient under observation. The 
principle involved is that a watery solution containing little solid matter 
will freeze at a higher temperature than one containing considerable solid 
matter. We should therefore expect that the urine from a diseased kidney, 
the eliminative function of which is thus diminished, would freeze at a higher 
temperature than normal; and that the blood of the same individual, through 
retention of solids, would freeze at a lower temperature than normal. 

Much effort has been given to this subject, as it readily can be seen 
that if an operation is under consideration, particularly upon the kidney, 
it is of great importance to know the condition of the remaining kidney. 
Kiimmell makes the following rule in cryoscopy: "The freezing point of 
normal blood is — 0.56° C. or higher; of normal urine, — 0.9° C. or lower. 
A freezing point of the blood of — . 58° C. or lower, or a freezing point of the 
urine of — 0.8° C, shows a degree of renal impairment which makes opera- 
tions upon the kidney dangerous and unjustifiable." 

"The following propositions have been emphasized: 1. The freezing 
point of the blood, notably depressed in cases of renal sclerosis, can be raised 
in the presence of chronic parenchymatous nephritis. 2. The freezing point 



DIRECTIONS FOR PREPARING SPECIMENS 55 

of the urine, which may be normal or sUghtly elevated in parenchymatous 
nephritis, is much higher in cases of renal sclerosis, even approximating that 
of the blood serum itself. Hence, 3. Inferences as to the condition of 
the kidneys are justified only by a consideration of the freezing point of 
both fluids, as well as of the total quantity of urine." 

"Uraemia, renal insufficiency, and renal permeability must be carefully 
distinguished ; they do not vary in constant ratio one with another. Urae- 
mia can coexist with permeable kidneys." 

Test : The test is simple. All that is required is a centrigrade thermom- 
eter, a large test tube, and a freezing mixture of ice and salt in a wide necked 
glass bottle. Two ounces of blood are drawn from the medium basilic 
vein with a cannula into the glass tube. Coagulation is prevented by 
constant agitation. The tube and thermometer are immersed in the freezing 
mixture. The freezing point of normal blood is . 56° C. to . 57° C. This 
test is made prior to a contemplated nephrectomy. A freezing point of 
0.59° C. demands caution. A freezing point of 0.60° C. is a positive 
contraindication to any operative interference on the kidney (Kiimmell, 
of Hamburg). Cryoscopy in connection with cystoscopy, segregation of 
urines, and the phloridzin test is to be regarded only as an aid to diagnosis 
— the examination should be prolonged over a number of days. (See also 
Renal Insufficiency.) 

Kapsammer has observed that the freezing point of urine may be in- 
fluenced by reflex polyuria from catheterism of the ureters. The result 
of this new method should be accepted cautiously. 

PHLORIDZIN 

Normal kidneys, according to present information, permit of the prompt 
transformation of phloridzin, injected subcutaneously, into sugar, while 
diseased kidneys fail to accomplish this transformation just in proportion 
to the lesion of the secreting cells. 

Caspar and Richter emphasize, as a preliminary to operation in cases 
of suspected renal insufficiency, the importance of estimating three factors — 
the quantity of urea excretion, the amount of sugar excretion after injection 
of phloridzin, and cryoscopy. They express the utmost confidence in the 
conclusions based upon these premises. 

DIRECTIONS FOR PREPARING SPECIMENS 

Serum Culture for Diphtheria. — Rub the cotton gently but freely against 
any visible throat exudate and subsequently rub the swab thoroughly 
over the surface of the blood serum. Do not allow the swab to touch any- 
thing but the throat and the serum. 

Urine. — Collect in a clean glass. To preserve it, add a few drops of 
chloroform or crystals of thymol. 

Sputum. — Collect and send in clean wide mouthed bottles. 

Blood. — For the malaria test. After carefully washing, prick the lobule 
of the ear or the tip of the finger, wipe away the first drop of blood, catch 
a minute drop of blood on a clean cover glass, cover the same lightly with 
a second glass, draw them quickly apart, and allow to dry. 



56 LABORATORY AIDS TO CLINICAL DIAGNOSIS 

Widal Test. — Place several separate drops of blood on a slide and allow 
them to dry without spreading. 

Red and white blood corpuscles can only be counted in a specimen 
accurately diluted. To determine the haemoglobin, use Tallquist's blotting 
paper at the bedside. 

Tumors and scrapings can be preserved in a 2 per cent solution of for- 
malin in sterile bottles. 



CHAPTER II 

GENERAL THERAPEUTIC MANAGEMENT 

Synopsis: Fever Diet. — Convalescent Diet. — Nutrient Enemata. — Subcutaneous Alimen- 
tation. — Gavage. — Lavage. — Low and High Flushing of the Colon and Colon Inflation. 
— Antipyresis by Medication.— Hydrotherapy, Baths, Packs, Douches. — Balneothera- 
peutics. — Stimulation. — Cold Air. — Enteroclysis. — Apparatus for Infusion and Hy- 
podermoclysis. — Drug Stimulation. — Management of Dyspeptic Symptoms.— Coated 
Tongue, Nausea, Vomiting, Thirst, etc. — I-axatives. — Diaphoretics and Diuretics. — 
Expectorants, Cough Mixtures, Inhalations. — Dyspnoea. — Pain in Acute and Chronic 
Illness. — Nervousness. — Insomnia in the Absence of Pain. — Counter Irritants and 
External Applications. — Venesection and Local Depletion. — Nasopharyngeal Toilet. 
— ^I'onics in Convalescent Stage. — Remarks on Mental Therapeutics. — Dose Deter- 
mination. — Practical Rules and Tables for Converting Apothecaries' Weight into 
that of the Metric System. — Invalid Bed. 

INTRODUCTORY REMARKS 

Therapeutics is the treatment of disease, not by medicines alone, but 
by any and all means and appliances. The only reliable basis of thera- 
peutical knowledge is clinical experience. 

The general therapeutic management embraces the treatment of symp- 
toms and conditions usually met with in acute and chronic ailments. 

In the absence of specific medication, which at the present time we have 
only for a very few diseases (diphtheria, malaria, syphilis, etc.), the manage- 
ment of acute febrile diseases is mainly hygienic and dietetic, coupled with 
the employment of rational antipyretic measures, timely stimulation, 
and careful attention to annoying or grave symptoms. 

The similarity of treatment particularly in all acute febrile affections 
makes it advisable, in order to avoid repetition, to discuss the general 
therapy in this separate chapter, to which the reader will be referred as the 
various diseases come under consideration. 

FEEDING IN SICKNESS 

Fever Diet. — A so called fever diet is essential in all febrile diseases 
or conditions. The food should be fluid or semisolid, so as not to overtax 
the feeble digestive apparatus or leave a large residue in the intestine for 
decomposition, which would be apt to favor autointoxication or local 
irritation. 

The attending physician will do well to write out a diet on a prescription 
blank or on the history chart to be kept by the nurse, and he may select 
from the list of liquid and soft diets to be found in the chapter on Nutrition 

57 



58 GENERAL THERAPEUTIC MANAGEMENT 

and Diet such articles as the patient may naturally desire, the list having 
been compiled with a view of meeting the demands of the adult sick. 

Breast fed or bottle fed children when ailing will naturally take less 
food than in health, particularly if kept in ill ventilated, hot, and stuffy 
rooms; but they will not require a change of food except in diarrhoeal 
diseases. A dilution of their ordinary bottle food or a longer interval 
between feedings is therefore indicated, and no special concern need be 
entertained if the little patient refuses to take its usual quantity of food. 

Boiled water should be offered to adults and children to quench thirst 
and favor excretion and elimination by skin discharges, the quantity of 
water to be given depending upon the requirements of each individual 
case. As pure water is not poisonous, it will never do harm. This rather 
superfluous remark is made for the encouragement of colleagues addicted 
to the drugging evil and more ready to prescribe drugs than to offer water. 

Special Diets. — For children who no longer take the bottle, we may 
select food from the following list: Water, toast water, farinaceous water, 
gum arabic water, white of egg in water, peppermint tea, imported ginger 
ale, black tea, milk, matzoon, kumyss, buttermilk, whey, sterilized, 
Pasteurized, peptonized, or malted milk, beef broth, mutton broth, 
chicken broth with and without egg, beef jelly, soups, gruels, corn- 
starch pap, pea soup, burnt flour, soup, eggnogg, tropon or somatose 
in peppermint tea, custard, ice cream, water ices, orange or pineapple 
juice, unfermented grape juice, champagne, California Tokay wine, .whiskey 
in water. 

Milk is contraindicated in dyspeptic and inflammatory diarrhoeas and 
in cases of milk idiosyncrasy, and also in cases of typhoid fever when the 
abdomen is markedly tympanitic. When milk is contraindicated, the fol- 
lowing articles on the list may be offered: Water, toast water, farinaceous 
water, black tea, gum arabic in water, white of egg in water, beef or mutton 
broth and egg, pea soup, and burnt flour soup. The latter is particularly 
useful in diarrhoeal disorders. 

An exclusive milk diet is indicated for infants up to eight months, and 
many practitioners favor an exclusive milk diet in cases of typhoid fever, 
in acute and chronic Bright's disease, in acute pyelitis, in chronic gastric 
catarrh, in gastric ulcer and cancer, in scarlatina, in neurasthenia, and in 
the Weir Mitchell rest cure. The writer is not convinced that a rigid milk 
regimen is superior to a more liberal bland mixed liquid diet. 

Peptonized Milk and Meat. — Peptonized food or predigested food is some- 
times serviceable when the digestive power is feeble, but in children it is 
frequently ordered unnecessarily and in cases in which it is positively 
harmful, as it adds to the intestinal putrefaction. This is particularly 
true when it is used for a long time. Under no circumstances should it 
be employed other than as a temporary makeshift. 

The writer seldom employs peptonized milk for children, and much 
prefers to aid digestion by administering a few drops of hydrochloric acid 
in sugar water after eating. 

Sarcopeptones, or Beef Peptonoids. — These are sometimes useful to 
tide over a critical period. If given for any length of time, they favor 
a putrid condition of the gastroenteric tract. Beef or sarcopeptones are 



RECTAL ALIMENTATION— NUTRIENT ENEMATA 59 

obtainable in the shops in a Hquid or semisoHd form, or they may be pre- 
pared by treating beef with an extract of pancreas, which is prepared by 
macerating for one week the pancreas of a pig, calf, or sheep with four times 
its weight of 50 per cent alcohol and filtering. 

RECTAL ALIMENTATION— NUTRIENT ENEMATA 

Feeding by the rectum is useful in feeble digestion and in cases in which 
food is not tolerated by the stomach, or to supplement a feeble stomach 
or inability to swallow, or in gastric ulcer and incessant vomiting, also 
in the insane. Before injecting food into the rectum, the latter should be 
cleaned by an enema. The patient is placed on the back with the thighs 
elevated, and a rubber tube of proper length is inserted into the rectum 
as far as it will go. The fluid food, consisting of an artificial fat emulsion 
or of milk or gruel with egg, whiskey, or peptonized food or somatose in 
watery solution, is allowed to flow into the rectum from an irrigator or 
fountain syringe. Various medicinal substances may be added to the enema 
if desired. Children will retain from two to eight ounces, and adults up to 
a pint. When the rectal tube is withdrawn, the buttocks may be pressed 
together to prevent the escape of fluid. 

Feeding in infectious fevers is a matter not clearly understood, for we 
practically know nothing regarding the difference in the behavior of mi- 
crobes in a starving and in a well nourished body. A child of seven, re- 
quiring a daily food value of 1,400 calories in health, probably takes only 
half a pint of eggnogg or one pint of milk in twenty-four hours when sick 
and feverish (which latter is equal to 400 calories), as in septic scarlatina 
with diphtheria, and rapidly emaciates, while some children take nothing 
or vomit everything given them. Now, the question is: Shall we let Nature 
take her course for a few days, or shall we endeavor to feed the body by 
nutrient enemata ? As the body fat is first burnt up in fever, we may wait 
a certain time, but not too long. Nutrient enemata are poorly absorbed; 
therefore we must not expect too much from rectal alimentation, for it will 
have but little influence in counteracting the pernicious action of bacterial 
products or toxins on the nerve centres. 

Subcutaneous feeding has been adopted to tide the patient over 
a critical period. The following formula has been used: 

Grape sugar, 5ss. ; 

Table salt, 3ss. ; 

Pepsin peptone, 5 j ; 

Water, ad. 5 jv. 

This to be injected under the skin in divided doses in twenty-four hours 
in severe cases of gastric ulcer or intestinal obstruction. Reports on the 
value of subcutaneous feeding are not encouraging. 

A preparation containing soluble albumin and table salt sold under 
the name of kalodol may be resorted to for subcutaneous feeding. 

Diet in the Convalescent Stage. — In the convalescent stage a liquid and 
soft diet may be selected from the list given in the chapter on Nutrition and 
Diet, with due consideration of the patient's natural likes and dislikes. 



60 



GENERAL THERAPEUTIC MANAGEMENT 



In the case of breast fed and bottle fed children, we gradually return to 
the food given when the child was in good health, unless the former method 
of feeding was faulty, in which case we select the proper food (see Infant 
Feeding). Older children may take in addition to their milk some of the 
following articles: Well cooked cereals, cornstarch pap, bread pudding, 

scrambled eggs, apple sauce, 
baked apples, scraped meat, 
calf's foot jelly, beef jelly, milk 
toast, sponge cake, biscuit, 
bread, zwieback, etc. 

GAVAGE 

Feeding by the stomach tube 
is accomplished by means of a 
soft catheter (No. 12 to 14) and 
a glass receptacle (a funnel of 8 
oz. capacity), as shown in the 
cut. Adults require a large tube 
and funnel. In rebellious pa- 
tients a mouth gag should be 
used, or the tube may be intro- 
duced through the nostril. 

Indications for Gavage. — 1. 
When patients refuse to take 
food, as in septic fever and 
coma, when rectal alimentation 
is inadequate. 2. In intubation 
cases when children cannot 
swallow or refuse to swallow. 
3. In habitual vomiting. Ba- 
bies are sometimes unable to 
retain food which is swallowed, but manage to keep it down when given 
by gavage. 4. In premature infants and cases of malnutrition. 

As soon as the food is in the stomach, the soft tube is pinched with the 
thumb and forefinger and rapidly withdrawn. The infant is not taken up 
until some time has elapsed, to prevent vomiting or regurgitation. In 
an infected stomach, lavage should precede gavage. 




Fig. 16. — Gavage. 
Feeding by means of the stomach tube. 



FLUSHING THE STOMACH AND BOWELS 

Stomach Washing — Lavage 

The most convenient and at the same time thorough way of washing 
a stomach is by means of the apparatus shown in the illustration. For 
children a fountain syringe is attached to a glass T cannula which has a 
flexible catheter at one end and a waste tube at the other. Adults swallow 
a soft rubber stomach tube — the wash water is introduced by means of a 
large funnel, which when lowered allows the fluid to return by siphon 
action. The stomach tube for adults is two feet long and joined to the 



FLUSHING THE STOMACH AND BOWELS 



61 



rubber tubing by means of a glass cannula. The funnel holds one pint. 
One or two funnelfuls are let in at a time and siphoned out by lowering the 
funnel. A return flow will be inter- 
fered with if the tube is bent upon 
itself or above the level of the fluid 
or blocked by food, etc. 

Two to four quarts of boiled luke- 
warm water in which a tablespoon- 
ful of sodium bicarbonate has been 
dissolved may be used at one sit- 
ting. Weak persons should be treated 
in bed. 

Average distance, 55 to 60 cm. 
from the teeth. Contraindications: 

Heart disease (advanced), aneurysm, recent hssmorrhages, including apo- 
plexy, advanced pulmonary disease, ulcer with recent haemorrhage. 

These rules do not hold good for all emergencies. 

In case of necessity the tube can be introduced through the nostril, 




Fig. 17. — Soft Rubber Stomach Tube. 




Fig. 18. — Stomach Washing in Adults. 



62 



GENERAL THERAPEUTIC MANAGEMENT 



in which position it will not be possible for any unruly child or insane 
adult to bite it. 

The child is held upright in the nurse's lap with the head secured in 
a forward position to allow saliva and vomited matter to escape by the 

mouth. In introducing the tube 
there is a slight hitch at the en- 
trance of the oesophagus, but it 
is easily overcome. When the 
tube is too large, it will com- 
press the larynx, and young 
children appear flushed and 
slightly cyanotic. When the 
clear cry of the child is heard, 
we know that the tube is not in 
the larynx. In letting in the 
water the stomach must not be 
filled to overflowing, unless it is 
necessary to expel large curds 
which would not go through the 
catheter No. 12 or 14. Over- 
flowing the stomach is safe only 
when the child's body is bent 
forward or it lies on its side. 
Stomach washing is an easy 
procedure in infants and chil- 
dren under two years. Stom- 
ach washing may also be accom- 
plished by means of swallowing 
warm water in the ordinary way 
and inducing vomiting by irritating the pharynx by the introduction of 
the fingers into the throat. 

Stomach washing in children is occasionally indicated: In acute gastritis, 
in acute poisoning, in cholera infantum, in chronic indigestion with atony 
of the stomach (to remove undigested 
food and foreign matters), in difficult feed- 
ing cases, in persistent vomiting, and 
previous to operations on the stomach. 

When it is necessary to simply clear 
the stomach of its irritating contents, a 
single washing is sufficient. In chronic 
cases washing every other day is neces- 
sary. The irrigation fluid is boiled water 
at the temperature of the body. Occa- 
sionally it is well to add a teaspoonful 

of bicarbonate of sodium to a pint of water to make it alkaline, 
is contraindicated in collapse. 




Fig. 19. — Stomach Washing in Infants by 

MEANS OF A FOUNTAIN SyRINGE, AT AN ELEVA- 
TION OF Four Feet. 

A T cannula connects reservoir stomach tube and 
waste pipe. 




Fig. 



20. — T Cannula 

TION. 



FOR Irriga- 



Gavage 



LOW AND HIGH ENExMATA AND COLON INFLATION 



63 



Enteroclysis — Low and High Enemata and Colon Inflation 

Flushing the colon in children and adults is accomplished by means of 
a soft rectal tube in the manner shown in the cut (soft rubber irrigating 
tube and a fountain syringe). 

The colon may be distended with boiled water, medicated water, starch 
water, soap suds, oil, air (by bicycle pump inflation), or carbonic acid gas 
(from an inverted siphon). Liquids as a rule do not penetrate farther than 




biG. 21. — liowKL Irkigation IX Jnfants and Childukx. 



the ileocaecal valve, but indirectly the entire gut will profit by lavage, by 
bringing down the contents from the small intestine and clearing the colon 
of putrid material. The value of irrigation depends somewhat upon the 
absorption of water by the large intestine. 

High Enemata. — The high enema is administered through a long cath- 
eter (colon tube) attached to a fountain syringe: To secure bowel action 
(use soap suds water, one half to two pints at a temperature of 101°-103° F.) ; 
to stimulate in circulatory failure; to prevent shock and collapse before 
chloroform anaesthesia, and before and after operations; in renal insuffi- 
ciency, uraemia (irrigate for twenty minutes at 110° with Kemp's flexible 



64 GENERAL THERAPEUTIC MANAGEMENT 

tube); in jaundice (irrigate with cold water at 60° or warm water at 110° 
F.) ; to reduce temperature (irrigate at 60°, 70°, 80°, or 90° F. Cold irriga- 
tions depress the heart) ; to replace lost fluids (irrigate at 110° F. as in weak- 
ness from haemorrhage) ; to overcome intestinal obstruction ; to nourish 
per rectum. 

Low Enemata are given with a short tube and have about the same 
indications as high injections, but are not quite so effective. They are some- 
times useful in subacute local inflammations of pelvic organs, but are or- 




FiG. 22. — Kemp's Rectal Irrigatou (Double Current Catheter). 

dinarily employed to secure bowel action. Colon Inflation by means of 
medicated water, oil, or gas, is practised to overcome bowel obstruction, 
and will be discussed more fully in the chapter on Intussusception, 

ANTIPYRETIC MEASURES 

Fever is characterized by a rise of temperature plus a disturbed metab- 
olism. A normal temperature is maintained by a complicated system of 
heat regulating apparatus, the details of which are more of physiological 
than of clinical import. An increase of temperature is usually accom- 
panied by increased frequency of respiration. In fever there is a con- 
traction of surface capillaries ; the skin cools off and the patient experiences 
a chilly feeling. Occasionally chills are observed with a high temperature, 
a reddened skin, and distended capillaries. A nervous chill is accompanied 
by no rise in temperature. In order to produce fever by infection, bacteria 
or other products must actually enter the circulation. The same holds 
good for Protozoa (malaria). We have no definite knowledge regarding 
the purely nervous irritation of the heat centres. The predisposition to 
high temperature varies with the individual and his age and condition. 
Young and strong individuals have a higher range of fever heat than the 
weak and aged. As a rule a continued high temperature is accompanied 
by loss of appetite and by inanition. Here again there are exceptions. 
The writer has known children and adults to have a temperature of 104° 
for over a week, though still an excellent appetite. 

The significance of fever for the organism is still a mooted question. 
On the one side fever is looked upon as a direct danger, and contrawise 
a high temperature is looked upon as favoring a limitation of diseased 
conditions. In many instances the thermometer has proved a stumbling 
block instead of an aid in practice, and even intelligent practitioners are 
frequently made uneasy by a rise of temperature in a patient, and resort to 
"premature antipyretic measures," thereby distorting the clinical picture 
of an ailment the nature of which is still in doubt. 



ANTIPYRETIC MEASURES 65 

Naturally our therapeutic efforts will vary according to our personal 
conception of such conditions. At the present time we are still in the dark 
regarding these points, and we do not exactly know whether fever due to 
infection is favorable or unfavorable to the animal economy. 

Our knowledge of subnormal temperature is meagre. Subnormal 
temperatures are not uncommon, and a continued subnormal temperature 
is a grave symptom, particularly in diseases usually characterized by high 
fever. Thus our antipyretic measures or efforts by means of hydrotherapy 
or chemical antipyretics may or may not be of value in a given case, but 
are probably rational as favoring increased elimination. 

DRUG ANTIPYRETICS 

Quinine as an antipyretic is indicated only in malarial fever. It is 
useless and often dangerous to depress the temperature by large doses of 
quinine in any other class of cases. 

Antipyrine, phenacetine, acetanilide, and lactoph^ine, also citrophen, 
may be used occasionally, one or two doses in the evening, when the tem- 
perature is at its highest, in order to reduce it for a few hours and overcome 
if possible the cerebral restlessness which makes sleep impossible. The 
routine and frequent administration of antipyretics as soon as the tem- 
perature reaches 103° is bad practice. 

Quinine Saccharinate (sweet quinine). — This new quinine product is 
now obtainable. It contains 67 per cent of the alkaloid and is therefore 
quite as efficient as the sulphate. It comes in crystal form or in compressed 
tablets, and is destined to take the place of the prdinary bitter quinine 
preparations. The dose is the same as that of the sulphate. Euquinine 
is a tasteless quinine preparation of about the strength of the sulphate, 
and has the same therapeutic indications. 

Quinine Sulphate (hydrochloride). — Dosage: Antipyretic dose, gr. 3 
to 15, suspended in compound elixir of taraxacum or in honey or given in 
a wafer. 

Antipyrine (soluble in water). — For children, single dose, gr. 1 to 3; for 
adults, gr. 5 to 15. Also per rectum in double dose. 

Phenacetine (insoluble in water). — Sedative and antipyretic, gr. 5 to 15 
for adults; gr. 1 to 3 for children, several times a day. 

Lactophenine (somewhat soluble in water). — Sedative, antipyretic; dose, 
gr. 5 to 15 for adults; gr. 2 to 3 for children, several times a day. 

Citrophen. — Same indications and dosage as phenacetine. 

Acetanilide (antif ebrin) . — Dose, gr. ^ to 2 for children; gr. 3 to 10 for 
adults, several times a day. 

HYDROTHERAPY, BALNEOTHERAPEUTICS 

Hydrotherapy plays a most important role in the management of acute 
and chronic illness by reason of the antipyretic and stimulating effects of 
baths, packs, and douches. The " hydrotherapeutic reaction " is the natural 
reaction of the body to heat or to cold. The temperature of the water 
should not be much above or below 90° F. 
6 



66 GENERAL THERAPEUTIC MANAGEMENT 

The Cold Bath. — When a person plunges into cold water or has a 
cold douche applied over a considerable area, he shivers and then takes 
a deep inspiration. The skin is cold and pale, but upon his leaving the 
water, if the reaction is present, it becomes red, and he feels a sense of 
warmth and breathes more easily. Voluntary motions, friction of the skin, 
and the general health and strength of the individual, as well as the tem- 
perature of the water, the length of the bath, and the force of the douche, 
govern the degree of the reaction. To one accustomed to the initial shock 
it is agreeable, and the reaction is more easily obtained. The flow of urine 
is increased, the action of the bowels is promoted, the appetite is stimulated, 
digestion is aided, and the nervous and muscular systems are toned up. 

The Warm Bath is sedative. The superficial vessels are dilated and 
there is a sensation of warmth. The respirations are increased in frequency. 




Fig. 23.— Hot Pack. 



Perspiration is increased. The sedative action is shown by the desire after- 
ward for rest and repose, while the effects of a cold bath are just the op- 
posite — a desire and ability for physical exertion, an increased energy. 
Hot applications tend to make one constipated. 

Hot air and hot vapor baths differ from hot water baths in favoring 
perspiration. One perspires most in hot air baths. 

Douche. — Douche is a term used to indicate a bath where a stream, 
the size of which may differ, is directed against some part of the body. 
The force with which it strikes the body acts as a powerful stimulant. It 
is usually directed against the back, along the spinal column. 

Turkish Baths are really dry hot air baths combined with a shampoo, 
massage, and cleansing. The temperature is raised to about 150° F. and 
sometimes higher. 



HYDROTHERAPY, BALNEOTHERAPEUTICS 67 

Russian Baths are exposures of the body to hot aqueous vapor, and 
the temperature of the room is often raised to 150° F. After the shampoo, 
massage, etc., the bather is subjected to a very cold douche. 

The Permanent Bath, or Hebra's Water Bed, is used for many 
skin diseases and other conditions. A tub long enough and deep enough to 
accommodate the prone body is arranged on legs like a bed, and a woven 
wire support upon which the patient lies is arranged on cogs so that it 
can be raised or lowered into the tub without disturbing him. A head 
rest is provided, so that the patient's head may be out of the water. In 
some cases the patient is left in the water continuously for months. The 
water should be warm, of about the temperature of the body, and it is 
changed by means of entrance and exit facilities about three times in twenty- 
four hours. The water may be medicated. In general it is employed for 
those conditions where a large surface is denuded of epithelium, as in 
ulcerative syphilides, psoriasis universalis, pemphigus foliaceus, dermatitis 
exfoliativa, lichen ruber acuminatus universalis, pityriasis rubra univer- 
salis, icthyosis, etc. In burns or injuries from freezing, gangrene, diabetes, 
endarteritis obliterans, phlegmon, urinary infiltration, decubitus, spondyl- 
itis, caries, etc., the permanent bath is of great benefit. 

Baths properly applied exert a tonic, eliminative, and antipyretic action. 

Mustard Bath. — An ounce of mustard is tied up in a muslin bag and 
thrown into the bath. The water may be of any temperature desired, 
105°, 100°, or 80°. 

The Cold Douche is not adapted for feeble cases. It is useful as a 
heart and nerve tonic. The patient stands in warm water and a pitcher 
of cold water (60°) is dashed over his back, after which he is rapidly dried 
and placed on a couch to rest. 

The Hot Pack is used in uraemia. The patient is wrapped in a sheet 
wrung out of water at 110°, and then in a blanket. This may be changed 
every half hour. 

Hot Bath. — The patient is placed in a bath at 100°, with cold applica- 
tions to the head. It is useful in collapse and to promote elimination by 
the skin. 

Hot Vapor Bath. — Hot air or vapor is introduced under the raised 
bed clothes from a croup kettle for twenty to thirty minutes. 

The Wet Pack (Priesnitz). — The bed is protected by a rubber sheet- 
ing, and a large Turkish towel wrung out of cold water is spread out in such 
a manner that when the patient is laid with his back upon the wet towel 
and wrapped up in the towel the trunk will be covered and the extremities 
and head free. The patient is then covered up to the neck with a woolen 
blanket. The wet pack can be changed every half hour or hour or two 
hours. 

Cool Sponging must be done under cover, or in a room heated to 80°, 
with alcohol and water or vinegar and water equal parts. Sponge from 
ten to twenty minutes to reduce the temperature and restlessness. The 
wet pack and cool sponging are the favorite hydrotherapeutic measures of 
the author in cases of children. 

The Cold Pack is for reducing persistent high temperature with 
delirium. The patient is enveloped in a sheet wrung out of warm water, 



^ GENERAL THERAPEUTIC !iIANAGEMENT 

and ice is rubbed over the entire covered body, while he lies upon a 
blanket in a bed protected by a rubber sheet. He may remain in the wet 
pack and the rubbing with ice be repeated as often as necessary. Hot 
water bags may be placed at the feet. This is to be employed only in 
extreme cases for adults and children. 

Warm and Cold Baths. — The patient is put into a bath at 100° and the 
water is gradually cooled to 80°, the trunk and extremities being rubbed 
while he is in the water or stimulated with hot water and whiskey. The 
bath may last from ten to twenty minutes. To prevent chilling, the tub 
may be covered with a blanket having a slit for the head to go through. 
It is for cases with persistent high temperatures with delirium. 

The Sheet Bath. — Where objection is made to the full bath, we 
make use of the "sheet bath," beginning with a temperature of 100° F. 
for children or 90° for adults. An old linen sheet or tablecloth should be 
used, and it should be wrung out very lightly. The patient having been 
wrapped in this, water at a temperature about ten degrees lower should be 
poured successively upon different parts of the body, and each part rubbed 
with the hands until it no longer warms up. 

The Ice Cap and Cold Coil are often efficacious in reducing tem- 
perature and restlessness in infants. They may be used continuously 
or intermittently, together with irrigation of the colon. 

Ice Poultice. — Cracked ice with bran or sawdust is wrapped in oiled 
silk or rubber cloth. The indications are the same as for the ice cap. 

Cold baths and cold packs should be employed with great caution and 
good judgment in infective fevers of children. Cool sponge baths, with or 
without alcohol, are stimulating and not depressing, and if supplemented 
by an ice cap or ice coil and flushing of the colon with cool water, will cer- 
tainly do no harm. A more decided antipyretic effect is accomplished by 
tubbing a child at 100° and gradually reducing the temperature of the water 
to 80° or 70° and applying friction at the same time. 

A warm mustard bath at 90° or 100° F. is well borne by feverish children 
and is an excellent means of starting or favoring elimination. In urgent 
cases in which a continued high temperature is the grave feature, the pro- 
longed or permanent bath is advisable, starting at 100° and reducing to 80° 
or 70°, and leaving the patient immersed for twenty to forty minutes. 
The writer has never seen ill results follow the cool pack by means of a sheet 
wrung out of cold water and applied all around the body from the armpits 
to the pelvis under a blanket. The extreme heroic application of cold 
water, either in the shape of tubbing or the cold pack with ice or snow, 
is in the author's opinion an unsafe procedure in children and in adults 
as well. 

BALNEOTHERAPEUTICS 

The drinking of much water tends to increase the watery secretions 
of the body, such as the urine, bile, saliva, pancreatic juice, and sweat. It 
thus aids in the excretion of the waste products. The benefit derived from 
the courses of mineral waters in a large measure is due to the liberal quan- 
tity of water consumed. Gout, urinary gravel, imperfect secretions of bile, 
constipation, etc., are conditions benefited thereby. (See also chapter on 
Nutrition and Diet.) 



STIMULATION 



69 



COLD AIR 

Inspirations of Cold Air in Fevers. — According to clinical experience, 
cold air inspirations have a positive value in febrile affections. Patients 
breathing cold air (adults and children) have a better digestion and 
sleep better than those in heated rooms. The phenomena of bronchial 
catarrh decrease to a marked degree under the influence of cold air inspira- 
tions, and the general course of 
disease appears to be favorably- 
influenced. 

Antipyresis by drinking large 
quantities of cold water, in con- 
nection with cool water entero- 
clysis and keeping open the win- 
dows of the room day and 
night, has given excellent results 
in cases of typhus and typhoid 
fever. Both these methods of 
antipyresis increase the quan- 
tity of urine and diminish its 
specific gravity, especially the 
drinking of water. Thus the 
internal organs, which have the 
highest temperature during fe- 
ver, are cooled, and the tissues 
are permeated and cleaned by 
the water and freed of pto- 
maines. 



STIMULATION 

When the physician suspects 
or recognizes circulatory failure, 
he resorts to methods of stimu- 
lation, as with alcohol, drugs, 

or enteroclysis and baths. When circulatory failure is due to shock or loss 
of blood (when an individual bleeds into his own blood vessels from vaso- 
motor paralysis) , the surgeon relies more upon hypodermoclysis and venous 
infusion than upon drugs. In the so called weak heart in acute infectious 
fevers, we have no clear conception of the exact nature of the circulatory 
failure, and at the bedside we are generally unable to determine whether 
heart weakness or vasomotor paralysis or both are present, and hence the 
choice of stimulants in a critical and grave case is not an easy matter. 
Laboratory experiments on animals poisoned with toxines have demon- 
strated that circulatory embarrassment, heretofore attributed to cardiac 
weakness, is due mainly to vasomotor paralysis, particularly in the early 
stages, whereas the late circulatory failure, in diphtheria for instance, 
appears to be due to cardiac weakness. In medical practice, and particularly 




Fig. 24. — Enteroclysis. 



70 



GENERAL THERAPEUTIC MANAGEMENT 



among children, drug stimulation and reflex nerve stimulation by means 
of cool water are almost exclusively relied upon. 

A moderate rise of pulse and temperature appears to be the indication 
for the administration of the various heart drugs in use at the present 
time. It is questionable whether early stimulation or promiscuous stimu- 
lation is in the interest of the patient. Unfortunately the indications for 
stimulation are by no means clearly understood, and no doubt in many 
instances we credit happy results to some particular drug or method when 
the inherent reserve power of the heart alone is responsible for the recovery 
of the patient. In view of the many disappointments and failures which 




Fig. 25. — Hypodermoclysis. 



we encounter in our attempts to keep the circulation going, there arises 
this very important question: Is stimulation by means of enteroclysis, 
hypodermoclysis, and venous infusion as effective and as safe in sepsis as 
in surgical shock, and in what class of cases may we employ them? The 
problem will be solved by clinicians at the bed-side. 

In June, 1903, at a meeting of the American Psediatric Society in Boston, 
the writer reported some observations bearing on this question from his 
hospital experience in cases of pneumonic, typhoid, diphtheritic, and 
puerperal sepsis, of which the following is a resume. 

From the study of the effects of saline infusion in shock and haemorrhage, 



DRUG STIMULATION. 71 

it would appear that this procedure and also hypodermoclysis ^ may be re- 
lied upon to promptly and safely stimulate in circulatory failure. And it is 
safe to continue with the saline until the pulse is of good quality. From a 
study of the septic cases treated by saline infusion it would appear that in 
order to remain on safe ground, it should be used for septic cases in which 
there has been a decided loss of fluids, as in cholera or typhoid diarrhoea. 
In cases of sepsis without loss of fluids, with an imperceptible pulse and 
rapid respiration in conjunction with a rapidly thumping and undilated 
heart, an infusion or hypodermoclysis may be warranted, but under no 
circumstances should these methods be employed in a routine way. 

Enteroclysis. — Enteroclysis, or flushing of the colon with a saline at 
110°, is an absolutely safe method of combating circulatory failure in septic 
conditions. It stimulates kidney secretion and promotes the elimination 
of poisons. It induces intestinal absorption of water when the body craves 
it, has a certain effect in reducing temperature, and is indicated as a routine 
treatment in all septic conditions even if the kidney is not involved. In 
severe anaemias the writer has found that enteroclysis is followed by an 
actual improvement of the constitution of the blood independently of the 
administration of drugs, such as iron or arsenic. 

Enteroclysis is performed by means of a long flexible tube and a fountain 
syringe, or by means of a double current flexible tube (Kemp's method). 
A tablespoonful of salt is dissolved in two quarts of water at 100° to 110°, 
and by elevating or lowering the fountain syringe the water is made to flow 
slowly into the bowel. In order to be effective, this must be kept up from 
thirty to sixty minutes and carried out by a trained nurse or by the physician 
himself. Enteroclysis should be universally adopted as a therapeutic 
measure of great value, and it may be used in connection with drugs, 
baths, etc. 

The advantage of enteroclysis over venous infusion in sepsis lies in its 
safety. When the heart muscle is weakened by the septic and febrile proc- 
ess, it is dangerous to suddenly increase the blood pressure, and there is 
also danger of carrying thrombi to other parts. The absorption of fluids 
from the intestine can only be slow and gradual, and not more can be 
absorbed than the organism craves. 

In general practice enteroclysis is readily possible, and hypodermoclysis 
or infusion demands a sterile manipulation which is often difficult to obtain. 
Enteroclysis should be our routine method in typhoid, smallpox, scarlet 
fever, measles, diphtheria, cholera infantum, eclampsia, and anaemia. 

Drug Stimvlation * 

We often administer drugs for the purpose of stimulation, such as 
alcohol, camphor, strychnine, nitroglycerine, digitalis, and ammonia, and 
also in connection with the cool douche or cold pack, with a view of effecting 
a reflex nerve stimulation. 

Alcohol. — The conclusion seems to be that, while alcohol cannot build 
up the body, it does serve as fuel to the body, and at the same time it is 

'The subcutaneous injection of a decinormal salt solution, 3vj of sterilized salt to 
one gallon of sterilized water at 100° to 120° F. 



72 GENERAL THERAPEUTIC MANAGEMENT 

capable to a certain degree of stimulating respiration. It is therefore 
of value in febrile disease and often aids to prolong life. 

In a general way, we may say that 

Whiskey, 5j to Sviij; 

Tokay wine, 5j to 1 pint; 

Champagne, . 5ij to 1 quart 

May be administered in twenty-four hours. 

Children take from five drops to a teaspoonful of whiskey in water at a 
time. Mild stimulants, such as coffee, black tea, and hot beef tea, may 
be given in connection with or instead of alcohol. Adults may require 
much larger quantities. 

Other drugs used are ether (spir. aether, comp.), gtts. 2 to 20 on sugar; 
ammonia (spir. ammon. arom.), gtts. 5 to 15 in sugar water; camphor, 
powder, or oil; digitalis powder, infusion, tincture, fluid extract; strychnine; 
nitroglycerine; caffeine. 

Strychnine, gr. -5V-5V; nitroglycerine, gr. y^-^V every three hours; caf- 
feine and sodium benzoate, gr. iij every three hours; camphor in oil (1-15) 
is a powerful stimulant and expectorant. Five to ten drops may be 
injected subcutaneously every three hours. 

When the stomach is not rebellious we obtain satisfactory results 
from 

Camphor, ^ 

Digitalis pulv., > aa, gr. j to iij. 

Acid benzoic, j 
q. 4. h. in sweetmeats or sweet chocolate. 

Timely and judicious stimulation is important in the management of 
disease conditions. Overstimulation is to be avoided, particularly over- 
stimulation by drugs. The reserve power of the heart in children is almost 
always to be relied upon except in malignant sepsis, and time and again 
drugs have received the undeserved credit of having sustained the patient 
in critical times. 

Stimulation, alcoholic or non-alcoholic, is contraindicated when the 
pulse is full and strong, and it may be injurious in such conditions. How- 
ever, when the pulse becomes weak and compressible, and long before it 
becomes intermittent, stimulation is necessary. 

Apparatus for Infusion and Hypodermoclysis. — A good infusion apparatus 
should possess the folio wirfg qualities: It should be cleanly, convenient, 
easily kept in order, and capable of being immersed in warm water in order 
to maintain the temperature of the contained infusion fluid as equable as 
possible. The temperature of the infusion fluid as it reaches the cannula 
should be known. Finally, the apparatus should be adapted for use in 
intracellular infusion. In the apparatus herewith figured the bottle is 
graduated in ounces. Through the rubber cork, which is secured by a simple 
clamp and screw device, two lengths of glass tubing are placed (A, B), 
the one reaching to the bottom of the bottle, the other terminating just 
within the bottle; in the course of the latter a bulb is blown in which a 



GENERAL SYMPTOMATIC MANAGEMENT 



73 



mass of cotton or lamb's wool is placed as an air filter. To the glass tube 
a rubber bulb is attached. To the long tube a length of rubber tubing is 
connected, and to the farther extremity is attached a piece of glass tubing 
in the interior of which a ther- 
mometer is placed. Finally, a 
conveniently curved metal can- 
nula is connected with the latter 
by a short piece of rubber 
tubing. 

The manner of emptying the 
apparatus is as follows: The 
bottle is filled with decinormal 
saline solution of the proper 
temperature. Hot- water is 
added to that in the basin from 
time to time, as required to 
maintain the temperature with- 
in the bottle. The infusion 
fluid is forced from the bottle 
by slow and steady strokes of 
the bulb, air being driven above 
the surface of the water, pass- 
ing through the filter on its way to the bottle. As much or as little 
pressure as may be desired may be made in this way, this being graduated 
according to requirements. 




Fig. 26. — Apparatus for Venous Infusion. 
(Dr. Fowler.) 



GENERAL SYMPTOMATIC MANAGEMENT 
DYSPEPTIC SYMPTOMS AND THIRST 

Coated Tongue, Nausea, Vomiting, Diarrhoea and Belching of Gas. — 
In acute and chronic illness digestion is always impaired and dyspeptic 
symptoms are complained of. After the bowels have been emptied with an 
enema or laxative drug, feeding the patient should not be pushed much be- 
yond the limits of a natural desire for food. A few drops of dilute hydro- 
chloric acid and frequent small quantities of cooled aerated water or iced 
black or peppermint tea will usually overcome nausea and vomiting, par- 
ticularly if the patient remains quiet in bed. In the presence of a coated 
tongue and foul stomach, it may be wise to get the patient to swallow a 
pint of warm water and to encourage emesis, and thus empty the stomach. 
In cases of obstinate vomiting, drop doses of tincture of iodine in sweetened 
peppermint water may be given every hour, and ice may be applied to 
the lower part of the spine. The vomiting and diarrhoea of acute gastro- 
enteritis in adults generally subside after a few doses of the following 
medicine: 

I^ Morphin. sulphat., gr. \; 

Tinct. Valerianae athereae, 5ij- 

Signa: 5 to 30 drops in cooled carbonated water or on cracked ice every 
hour until relieved. 



74 GENERAL SYMPTOMATIC MANAGEMENT 

Morphine should be given to children only in very exceptional cases. 
Incessant vomiting is encountered in bowel obstruction, in cerebral cases, 
in virulent septicsemia from various causes, and in intense intestinal putre- 
faction from obstinate constipation. Stomach washing with a tube is 
occasionally necessary to overcome this symptom. Thirst may be relieved 
by giving cooled carbonated or farinaceous water, or cracked ice and water, 
and iced tea. In some cases the sipping of warm water, or the sucking of 
a raw prune, will relieve thirst. To prevent drying of the mouth a moist- 
ened piece of plain gauze may be applied over the lips, and the mouth 
should be frequently rinsed and a few drops of salt water poured into the 
nostrils occasionally. 

LAXATIVES IN ACUTE ILLNESS 

It is hardly ever a mistake to begin the treatment of a case of acute 
illness by first emptying the bowels. This can be accomplished in children 
and adults by a soap suds enema from 4 oz. to 2 quarts, or by the administra- 
tion of drugs. Children should have from two to five grains of calomel, 
to be followed by a saline, or may take a wineglassful of citrate of magnesia 
or half a teaspoonful of rhubarb and magnesia or maltine with cascara or 
a tablespoonful of castor oil. Powdered castor oil is now in the market 
under the name of Ricinus Siccol. It is tasteless and contains 50 per cent 
of oil and may be given in milk without the patient knowing it. 

It is a weak preparation at best. 

Adults may take Hunyadi, apenta or Rubinat waters, tamar indien, 
infusion of senna with sodium sulphate, 

or Podophyllin, . . . . gr. J to i, ^ 

Calomel, gr. 5 to 10, >pro dosi; 

Pulv. aromat., gr. iij, j 

or compound licorice powder,. . 3j to 5ij, pro dosi. 

Laxatives for chronic constipation are discussed in the chapter on Con- 
stipation. 

DIAPHORETICS AND DIURETICS 

Diaphoretics. — Elimination by the action of the skin and kidneys is 
often accomplished by means of so called diaphoretics and diuretics. To 
induce sweating we employ in adults and children the hot bath, hot pack, 
and hot drinks, such as peppermint, chamomile, catnip tea, and hot lem- 
onade. The most powerful diaphoretic drug is pilocarpine (jaborandi), 
which may be given in -^j to J grain doses to children and adults every 
two to three hours until the desired effect is produced. The dose of infusion 
of jaborandi is 2 to 3 drachms. Owing to its heart depressing effects, it 
is not an absolutely safe drug in septic fevers with a dry skin, and it is 
therefore not employed to any great extent by careful physicians who 
are anxious not to do harm. In collapse from pilocarpine there is usually 
a cold perspiration, with a fine rapid and intermittent pulse, and in extreme 
cases profuse salivation and pulmonary oedema. It may be well to remem- 
ber that pilocarpine and atropine are antagonistic. When the stomach 



EXPECTORANTS AND COUGH MIXTURES 75 

is not rebellious, the following diaphoretic powder may be taken with a 
hot drink at bedtime: 

I^ Pulv. doveri, gr. 5 -10; 

Camphorae, gr. ^-1 ; 

Pulv. chocolad., gr. 20. 

M. sig., one dose. 

Diuretics and their Doses. — Drugs which increase arterial pressure or 
salts which are readily diffusible and combine with water are useful as 
diuretics. The following drugs may be used singly or in combination: 

Infusion of digitalis, in 5j doses for children; in 5iv doses for adults, 
about every three hours. 

Tincture of digitalis, gtts. 5 to 30, four times a day. 

Fluid extract of digitalis, gtts. 1 to 5, also subcutaneously, in urgent 
cases. Watch for a cumulative effect and the digitalis pulse. 

Tincture of Strophanthus. — Rapid action; no cumulative effect; dose, 
gtts. 5, four times a day. Also in tablet form as strophanthin; dose, jjrs 
to Tih gr- 

Squill. — Fluid extract; dose, gtt. 1 to 3. 

Caffeine, Sodium Benzoate. — Readily soluble in water; dose, gr. 1 to 5 
for adults, gr. 1 to 2 for children. Also subcutaneously. 

Theobromine Sodium Salicylate (Diuretin). — Readily soluble in water. 
Should be employed when digitalis and caffeine are used without success. 
The dose is gr. x to xv four to six times a day. The diuretic action 
should be noticeable within one to three days. 

Camphor. — Gr. 1 to 3 for adults; ^ to 1 for children, with sugar or 
chocolate. In oil (1 to 15), subcutaneously. Also in combination with 
digitalis and benzoic acid. 

Calomel or Blue Mass. — Gr. 5 to 10, twice a day for two days. May 
be given in combination with jalap. 

Acetate of Potassium. — Soluble in water. Dose, 10 to 60 gr. three times 
a day. When diuresis is to be stimulated, it is often a good plan to begin 
with calomel or blue mass and follow up its effects by the administration 
of other diuretics of the foregoing list, together with hot drinks. When 
patients do not urinate, we must not fail to examine the bladder for a 
possible retention of urine. 

EXPECTORANTS AND COUGH MIXTURES 

A cough is an expulsive effort at expectoration, and unless extremely 
harassing should not occasion alarm. When a cough takes its origin in 
the nasopharynx, the nasopharyngeal toilet (salt water and albolene spray) 
is indicated, or local cauterization with a 2 per cent solution of nitrate of 
silver. To allay reflex irritability and check cough, opium and its prepara- 
tions may be given, with or without expectorants. Expectorants are 
occasionally necessary to aid nature in expelling secretions, particularly 
in feeble children and very old people. 

Ipecac, ammonia, benzoic acid, camphor, and iodide of potassium are 
examples of expectorants. Free expectoration is more readily obtained 
when the patient receives plenty of water. 



76 ^' GENERAL SYMPTOMATIC MANAGEMENT 

The writer makes use of the following formulae in his practice: 

I^ Tinct. opii camphoratae, 3ij- 

Signa: 5 to 15 drops in sugar water once or twice at night to check 
cough in a child. 

I^ Tinct. opii camphoratae, 1 __ ^.. 

Vini. ipecacuanhae, j ' ^' 

Dose, 10 to 15 drops. Sedative and expectorant for a child. 

I^ Liq. ammon. anisati., 3ij- 

One-half to 5 drops in sugar water several times a day for children and 
adults. Expectorant. 

I^ Ammon. chlorid., 5j ; 

Morphin. hydrochloride, gr. i ; 

Aquae, 



Syrupi pruni virginian, / ' ^' 

Dose, a teaspoonful every three hours for adults, to check cough. 

I^ Pota'ssii iodidi, 5ij ; 

Tinct. opii camphorat., 5ij ; 

Liq. ammon. anisat., 3ss. ; 

Syrupi Tolutani, 5ij ; 

Aquffi, ad., 5jv. ^- 

Dose, i teaspoonful to one tablespoonful three to four times a day. An 
expectorant for children and adults. ^ 

Sedatives for adults. 

I^ Codeine, gr. J to gr. ij, ^ 

Morphine, gr. | to gr. ^, > pro dosi. 

Heroin, gr. tV, J 

May be given in powder or tablet form in solution with syrup of Tolu 
or mucilage, or subcutaneously. 

. I^ Camphorae tritse, gr- j; ) 

Acid, benzoic, gr. iij, > pro dosi. 

Extracti hyoscyami, gr. i, j 

In water or capsule or in powder form, to be taken in sweetmeats three 
times a day as an expectorant for adults. 

Terehene and terehene hydrate may be taken internally for any form of 
chronic bronchitis. As an expectorant the dose is from 4 to 20 drops in 
syrup or on sugar, also in combination with heroin, and it may be admin- 
istered by inhalation in all throat affections (2 oz. in a week). Sedative 
and expectorant troches are sold in the shops ready made. They are 
useful in slight ailments. Black Forest pine needle troches, Ems pastilles, 
and red gum lozenges are useful to allay cough. 

* Ether is a powerful expectorant in subacute and chronic bronchitis. Adults may 
take 5 to 10 drops on sugar several times a day. Children may take 1 to 2 drops. 



DYSPNCEA 77 



INHALATIONS 



k 



The various saline antiseptic and balsamic inhalants in the shape of 
vapors and sprays are of little value as compared with the soothing effects 
of breathing and living in the pure, fresh, dust free air of the mountains 
or the seashore. Inhalation therapy is quite popular among the laity and 
is a routine method of treatment in sanatoria.^ In private practice, in 
cases in which a moist atmosphere would favor expectoration, the humid- 
ity of the air of the sick room may be increased by evaporating water 
from an open vessel or croup kettle over a flame, and to the water may 
be added oil of turpentine, oil of eu- 
calyptus, compound tincture of benzoin, i|jjj| 
terebene, creosote, etc. lif 

The upper respiratory tract may be mbk 

lubricated by means of an inexpensive H J \ ^ 

hand atomizer containing benzoinated ^^3|1 >g||il!P!||*^^ 

Adults may directly inhale hot med- mm \ t^UT^^ '"'" ' i 

icated moist air by sprinkling the sub- m »j| |\***Atii» ,, 

stance to be inhaled upon several layers B! jli ' i 
of flannel wrung out of hot water and Q^gg^^^ _^ 

held directly over the face. Oxygen Fig. 27.— Atomizer for Albolene. 
inhalations are employed in a routine 

manner— the author has never observed any marked beneficial effects from 
oxygen inhalations in hospital or private practice. Inhalations of ozone, 
iodide of ethyl, amyl nitrite, and chloroform are occasionally employed on 
special indications — also the vapors of stramonium and nitre and in the 
form of cigarettes. 

DYSPN(EA 

This is a very distressing symptom, and a careful study and determina- 
tion of its immediate and remote causes will aid in suggesting the means of 
affording relief. An embarrassed heart or lung may require venesection 
or drug stimulation; general oedema, ascites, or hydrothorax may necessi- 
tate in addition scarification and puncture and subsequently morphine 
or chloral at night to secure rest. A d3^speptic and neurotic dyspnoea will 
often pass off after we have given the patient 10 to 20 drops of compound 
spirit of ether on sugar. The dyspnoea of arteriosclerosis and Bright 's 
disease usually demands morphine subcutaneously administered.^ Dys- 
pnoeic patients breathe easier in an upright position; thus in severe cases 
the patient may sleep in a Morris chair or in bed in an upright and forward 
posture, the arms and head resting on a benchlike support. 

* From experiments made to show the behavior of atomized fluids in the respiratory tract 
it has been shown that a considerable portion of the inhaled cloud condenses on the pos- 
terior pharyngeal wall, and that the quantities reaching the deeper parts are too minute to 
have any therapeutic value. 

'Neurosis of the phrenic nerve with diaphragmatic inactivity or spasm has been 
observed as a cause of dyspnoea. 



78 • GENERAL SYMPTOMATIC MANAGEMENT 



PAIN IN ACUTE AND CHRONIC ILLNESS 

Pain, if severe, should be relieved; sometimes change of position or 
the application of a cold compress or hot water bag or mustard plaster 
will relieve pain. Pain, if localized and severe, is best overcom'^ by means 
of a hypodermic injection of morphine, gr. J to i, as in rheumatic arthri- 
tis or intestinal or biliary colic, or after injury. Pelvic and rectal pain 
may often be relieved by a suppository of 

I^ Extr. opii, ) _ _ , 

Extr. belladonna, P^' ^^' ^' 

Butyr. cacao, gr. 10 ; 

to be applied per rectum or vaginam. In severe enterocolitis in chil- 
dren a suppository of these drugs in yV of the dose mentioned is often of 
great value. 

Neuralgic pain may necessitate a hypodermic injection directly over 
the seat of the pain. Frequently a dose of bromide of potassium or chloral 
hydrate, by inducing a restful sleep, will overcome pain. Neurotic in- 
dividuals should not be encouraged in the use of opium and anodynes 
for moderate pain. 

NERVOUSNESS AND INSOMNIA IN THE ABSENCE OF PAIN 

These are very distressing symptoms. A warm bath, a cooling sponge 
bath, an ice cap, and, in adults and older children, the quiet assurance that 
all will be well, may quiet a patient. The following drugs are occasionally 
of great service: Codeine, by the mouth, gr. ^ to ij for adults, ^V to iV for 
children. 

^ Codein., gr. j to ij, ) ^^ ^^^. 

Urethane, gr. 30, ) ^ > 

To be taken at bedtime (for adults). 

I^ Hydrate of chloral, 1 _ _ i r: + qo 

Potass, bromide, / ' '° ' 

Dose for an adult. ' 

Or hydrate of chloral and potass, bromide, aa, gr. 1 to 2, for a child, 
in sweetened water or per rectum. 

Or trional or sulphonal in 15 gr. doses in milk, for adults. 

In cerebral unrest hyoscine (Merck) is indicated. Dose for the insane, 
gr. -gV; for the sane, gr. Yhif (may be repeated). In insomnia with 
pain or severe dyspnoea a hypodermic injection of morphine is often neces- 
sary. If the insomnia and dyspnoea are due to massive pleuritic effusion 
or ascites, the liquid must be removed; if to pulmonary congestion, a vene- 
section should be done. The writer has been disappointed in lactucarium 
and hasheesh as dispensed in our country. Beer or porter at bedtime may 
induce a quiet sleep. 

Counterirritants and indifferent external applications have no scientific 
or precise indication. The writer makes use of the ice bag, hot water 



VENESECTION AND LOCAL DEPLETION 



79 



bag, and cold wet compress. The latter should be used in connection with 
rubber sheeting or oiled silk, to prevent general wetting of the bed. Poul- 
tices may be discarded as offering no advantage over the bag, and the 
physician need not support superstitious ideas by speaking of pneumonia 
jackets, etc. 

As counterirritants, dry cupping, mustard baths, mustard plasters, can- 
tharides plasters, and iodine preparations are useful. Soothing external 
applications and percutaneous therapeutics are discussed in the dermato- 
logical memoranda and other special chapters in this book. 



VENESECTION AND LOCAL DEPLETION 

In cardiac and respiratory embarrassment, when compression of the 
arm below the shoulder produces marked distention of the veins below 
(forearm and elbow), and when heart drugs fail to stimulate the lagging 




Fig. 28. — Technique of Venesection. 



heart muscle, the unloading of the heart or embarrassed circulation by 
venesection is indicated. Six to fifteen ounces of blood may be withdrawn. 
Local depletion by means of scarification and puncture, wet cupping, 
or leeching is performed in ophthalmic and aural practice for the relief of 
local hyperemia or congestion. Leeches will readily attach themselves 
if the parts are washed in ice cold water and then slightly scarified as for 
vaccination. After the leech drops off, the bleeding point will continue to 
bleed if hot cloths are applied. In case of too profuse haemorrhage, ice 
cloths and compression may be used. Scarification is sometimes employed 
in lymphangeitis and erysipelas, followed by a wet antiseptic dressing. 



80 



GENERAL SYMPTOMATIC MANAGEMENT 



Venesection in Children. — This may be indicated in respiratory failure 
and for the purpose of relieving an embarrassed heart in 



Bronchitis, 

Pneumonia, 

Cardiac lesions, 

Convulsions due to congestion of brain 
and in uraemic conditions, 



Cyanosis 

and 
Dyspnoea. 



From one to three ounces of blood may be removed. Venesection in 
children is not often practised. 

The Technique of Venesection. — The arm is constricted between the 
shoulder and elbow by means of a silk handkerchief. The region of the 




Fig. 29.— Dry Cupping. 



bulging median vein is cleansed and made anaesthetic by injecting a 2 per 
cent cocaine or stovaine solution. After incising the skin the vein is 
punctured. A firm bichloride compress will stop the bleeding. 



THE NASOPHARYNGEAL TOILET 

The nasopharyngeal toilet, as advised by the author in all febrile diseases, 
consists in the instillation into each nostril, by means of an ordinary tea- 
spoon, of a spoonful of weak salt water morning and evening (at bedtime 
and on rising) as the children lie on their backs with the nose tilted up and 
the mouth open. The liquid does not wash through at once; some of it 
remains in the various recesses of the nasal cavity and is eventually sneezed 



THE NASOPHARYNGEAL TOILET 



81 



out or swallowed. In this way putrescible matter and bacteria are washed 
away. 

This form of mechanical antisepsis is indicated as follows: It is the 
best method of local treatment of all cases of diphtheria, in which instances 
it should be resorted to every two hours ; moreover, it is the most satisfac- 




FiG. 30. — Nasopharyngeal Toilet (Author's Method). 

tory local routine treatment in all diseases in which diphtheria frequently 
sets in as a complication, e. g., in measles, scarlatina, and pertussis; fur- 
thermore, it is a necessity before and after amygdalotomy and all operations 
on the nose and throat. This method is far superior to gargling, and the 
writer, after an experience of more than fifteen years with this method, 
again takes pleasure in recommending it on account of its great value and 
harmlessness. In many forms of reflex cough, also in pneumonia and 
tuberculosis, it is far superior to nauseating expectorant mixtures, and in 
all forms of febrile disease in which the nasal secretion becomes dry, crusty, 




Fig. 31. — Blunt Nasal Irrigation Syringe. 



or hardened, half a teaspoonful of salt water instilled into each nostril 
affords much relief. The nasopharyngeal toilet not only does not provoke 
middle ear and sinus complications, but apparently prevents them. If 
chemical antisepsis is in addition urgently demanded, as in malignant sore 



82 GENERAL SYMPTOMATIC MANAGEMENT 

throat, we may employ a 5 per cent solution of ichthyol in water or a 
bichloride of mercury spray, 1-10,000. The surface of the nose may be 
covered with vaseline, and an albolene spray may be used to advantage 
in some cases when the watery fluid is not soothing enough. See also 
article on Diphtheria in Paediatric Section. 

TONICS IN THE CONVALESCENT STAGE 

The best general tonic after acute illness is probably a change of air, 
from the city to the country, from the mountains to the seashore, and 
vice versa. A regulated digestion and exercise, massage, baths, and restful 
surroundings are welcome to every convalescent. The administration of 
dilute hydrochloric acid after meals will aid digestion, and a normal diges- 
tion and good food will soon bring the blood composition up to the proper 
standard. 

Hydrochloric Acid. — 

I^ Acidi hydrochlor. dil., 5jv. 

Five to ten drops in sugar water after eating. 

I^ Acidi hydrochlor. dil., \ -- ^' 

Tinct. nucis vomic, ) ' ^" 

Five to ten drops in sugar water after eating. 

I^ Acidi hydrochlor. dil., 5j; 

Ess. pepsini, 3ij- 

A teaspoonful in water after eating. 



I^ Acidi hydrochlor. dil., 
Tinct. gentian, comp., 
Tinct. rhei vinos., 
Tinct. cinchonse composit.. 

Half a teaspoonful in water after eating 



■aa, 5jv. 



I^ Acidi hydrochlor. dil., 

Tinct. quassias, ) ^^' ^^' 

Ess. pepsini, q. s. ad., 5iij. 

A teaspoonful in water after eating. 

I^ Acidi hydrochlor. dil., 5j; 

Bismuthi subnit., 5 j ; 

Ess. pepsini, 5jv. 

A teaspoonful in water after eating. Shake well. 

If iron, arsenic, phosphorus, and other drug tonics are to be given, the 
tongue must first be clean, and should a clean tongue become coated after 
the administration of drug tonics, the latter should be discontinued and 



MENTAL THERAPEUTICS AND WORK FOR THE SICK 83 

hydrochloric acid substituted. The author uses the following formulae 
in his practice for ansemic convalescents: 

Tinct. Jerri, chlorid., in doses of 2 to 20 drops three times a day, 
Tinct. Jerri, pomati, 5 to 20 drops three times a day. 

I^ Elixir gentianse comp., 5ij ; 

Tinct. ferri. chlorid., 5j- 

Dose, ^ to 1 teaspoonful three times a day. 

Liquor Peptomangan. — Dose, 5 to 15 drops three times a day. 

Liq. Bromo Mangan. — Dose, 5i to 5j- 

Elixir Calisayce Cum Ferro et Strych. — Dose, 5j to 5jv several times 
a day. 

Also the glycerophosphates and hypophosphites of iron and iron tropon. 

Arsenic is best administered in the shape of Fowler's solution, 1 to 5 
drops in water three times a day after eating. 

Phosphorus in the shape of Thompson's solution may be given to chil- 
dren in 10 to 20 drop doses three times a day in water. Elixir of phosphorus 
is a palatable preparation. Phosphorus chocolate lozenges may be given 
to children as candy. Adults take larger quantities. 

A very good alcoholic malt tonic for convalescents is barley wine, and 
several of the large brewing companies of our country make a palatable 
malt beverage containing little or no alcohol. 

Malt and maltine preparations are beneficial for convalescents. 

MENTAL THERAPEUTICS AND WORK FOR THE SICK 

The influence which may be exerted on the minds of the patients is of 
the utmost importance in acute as well as in chronic ailments. Abnormal 
mental conditions lead to an exaggeration of symptoms, to imaginary ail- 
ments, and to undue apprehension, which interfere (by a general depressing 
effect upon bodily functions) with the favorable progress of disease. De- 
termination and a strong will are efficacious in resisting and overcoming 
disease. Lives are made miserable by injudicious injunctions to rest from 
work or by failing to suggest some congenial work. Old people who are 
apt to become introspective and a burden to themselves are often made 
happier if they go back to nature and spend their declining years in the 
country, where they can always find some form of pleasant occupation 
during the day and rest and quiet surroundings at night. In chronic 
ailments the tactful physician will hold out to the patient the encouraging 
features of a case, and not " imitate a judicial sentence of death " by telling 
the patient that he is in no immediate danger and that he may live for 
several weeks or months. A hopeful attitude toward the patient is 
always correct and ethical. It prolongs life and alleviates suffering. 

In conclusion, I wish to emphasize that the important points in the 
management of acute febrile disease are diet, hydrotherapy, rational stimu- 
lation, and free breathing of pure cool air. Drugs no longer dominate our 
therapeutics. After the bowels have been made to move, drugs are not 
indicated, unless for some special and substantial reason. The more in- 



84 



GENERAL SYMPTOMATIC MANAGEMENT 



telligent part of the community have lost faith in drugging, and medical 
men should not continue to countenance or encourage superstition as to 




Fig. 32. — Infection and Sloughing of the Skin from Unclean Hypoderm.\tic 

Injections. 

drugs. When a placebo seems indicated, a few drops of hydrochloric acid 
in sugar water or in essence of pepsin are rational and will do no harm. 
Infants do not require a placebo, and young and inexperienced mothers 
should be gently but firmly enlightened on such matters. Drugs may be 
administered by the stomach, by the rectum, by inunction, or by hypo- 
dermic injection, with reference to the local or general therapeutic activity 
sought. 

Dose Determination. — Regarding dose determination, it is well to re- 
member the ^V rule advanced by Dr. V. C. Pedersen, of New York: A full 




Fig. 33. — Bed Grapple for the Comfort of Patients. 
(From the Medical Council, 1904.) 



therapeutic dose will be tolerated by a subject twenty years of age and 
upwards; the proportionate dose for any age, twenty years or less, is found 




Fig. 34. — Feely Invalid Bed. 




Fig. 35. — Feely Invalid Bed. 



86 



GENERAL SYMPTOMATIC MANAGEMENT 



by taking ^ of the full dose and multiplying the result by the age in 
years or fractions of years. 

The Metric System in Prescription Writing has made but little progress 
in the United States. 

To facilitate the conversion of apothecary's weights and measures into 
the metric system the following tables and rules are not too cumbersome 
and tedious for practical use: 

To convert ounces into grammes, multiply by 30. 

To convert grammes into ounces, divide by 30. 

To convert troy grains into centigrammes, multiply by 6. 

To convert centigrammes into troy grains, divide by 6. 

To convert troy grains into milligrammes, multiply by 60. 

To convert milligrammes into troy grains, divide by 60. 

To convert troy grains into grammes, or minims into fluid grammes, 
divide by 15. 

To convert grammes into grains, or fluid grammes into minims, multiply 
by 15. 

To convert drachms into grammes, or fluid drachms into fluid grammes, 
multiply by 4. 

To convert grammes into drachms, or fluid grammes into fluid drachms, 
divide by 4. 

PRACTICAL APPROXIMATE GRAMME VALUES 



Grains 


Grammes 


Grains 


Grammes 


Grains 


Grammes 


Grains 


Grammes 


i 
i 

i 


0.004 

0.005 

0.006 

0.008 

0.010 

0.015 

0.02 

0.03 

0.05 

0.06 

0.12 

0.20 


4 

5 


0.26 
0.30 


20 Oj) 
24 

30 ( 3 ss) 


1.3 
1.5 
2.0 


100 


6.6 


120 
150 
180 
240 
300 
360 
420 
480 
3ij 


8.0 






10.0 


8 


0.52 


36 

40Oij) 


2.3 
2.6 


12.0 
16.0 


10 


0.60 


20.0 


f 

1 






24.0 






60(3j) 


4.0 


27.0 


15 


1.00 


30.0 


2 






60.0 


3 


18 


1.20 


90 


6.0 


120.0 



Invalid Bed. — In severe or protracted illness a properly constructed 
invalid bed or bed grapple is a great convenience for patient and nurse. 
(See Illustrations.) 



CHAPTER ni 

PEDIATRICS 

Synopsis: Care of the New-Bom. — Diseases of the New-Bom. — Deformities. — Malforma- 
tions. — Infant Feeding. — Facts about Milk. — Maternal Nursing. — Cow's Milk for In- 
fant Feeding. — Diet for Children after Weaning. — Ailments of the Mouth in Infants 
and Children. — Mumps. — Indigestion and Diarrhceal Disorders. — Malnutrition. — 
Rickets. — Marasmus. — Scurvy. — Worms in Children. — Tuberculous Peritonitis in 
Children. — Diseases of the Respiratory Tract in Children. — Colds, Bronchitis, Pneumo- 
nia, Pleurisy, Empyema, Whooping Cough. — ^Pyothorax. — Thymus Gland. — Bronchial 
Lymph Nodes. — The Nasopharynx. — Diphtheria and Croup. — Intubation and Tra- 
cheotomy. — The Nasopharyngeal Toilet. — TonsiUitis. — Peritonsillitis. — Quinsy. — En- 
larged Tonsils. — Adenoid Growths. — Retropharyngeal Lymphadenitis and Abscess. 
— Eruptive and Other Fevers in Children. — -Measles, Rubeola, Scarlet Fever, Malaria, 
Typhoid Fever. — Glandular Fever. — Vulvovaginitis and Masturbation. — Familiar 
Forms of Nervous Derangements Peculiar to Early Life. 

INTRODUCTORY REMARKS 

In this section the author presents in a clinical garb the diseases which 
are peculiar to early life or show marked peculiarities in infancy or child- 
hood. In order to avoid unnecessary repetition, no attempt has been made 
to enumerate and discuss all diseases occurring in children, and when an 
apparent omission is noticed, particularly as regards skin lesions, urogenital 
and circulatory disturbances, etc., which present no marked difference in 
childhood, the reader will find the matter discussed elsewhere. 

CARE OF THE NEW-BORN 

The Cord. — Express the excess of gelatine from the cord, dust with 
subnitrate of bismuth, and wrap in aseptic gauze or absorbent cotton, 
after which the flannel binder around the abdomen may be applied. The 
dressing is not to be unnecessarily disturbed, and may be removed at the 
time the cord separates from the body, about the fifth or seventh day. The 
stump may then be dusted with mild aseptic powder and a small pad 
placed in situ. The cord stump is practically healed about the tenth day. 

Asphyxia. — This condition when present will call for prompt relief. 
The infant is cyanotic, livid, or frequently, when the asphyxia is deep, 
the child presents a pale, deathlike appearance. This condition is due to 
many and various causes, prominent among which are inherent weakness 
of the child, pressure of the cord about the neck, prolonged labor, undue 
presguje exerted on the head by forceps, aspiration of mucus, blood, or 

87 



88 PEDIATRICS 

amniotic fluid, or illness of the mother (convulsions during labor, amesthesia, 
etc.). In attempting to reestablish the respiration, there are many methods 
of resort. First, clear the mouth and pharynx with a swab of cotton to 
disengage accumulated mucus. If mucus or fluid obstructs the trachea, 
aspiration by the rubber catheter is indicated. Applications of alternate 
hot and cold water and spanking are mechanical means of favoring better 
respiratory efforts and assisting the flagging circulation. Mouth to mouth 
inflation, with the infant's head thrown back, may be tried. Sylvester's 
and Schultze's methods of inducing artificial respiration are commendable, 
also, rhythmical traction of the tongue. After the reestablishment of 
respiration, the infant should be observed for some hours, and one or more 
of the combined methods above indicated resorted to in instances demand- 
ing repetition. Asphyxia may result in cerebral congestion, effusion, 
thrombosis, extravasation, and destruction of nerve tissue with secondary 
inflammation and cystic degeneration. Prolonged asphyxia of the new- 
born may result in idiocy; about 40 per cent of the idiots who were first 
born children have a history of asphyxia. The longer the duration of 
asphyxia, the greater the danger. The immediate treatment of asphyxia 
is therefore very important. 

Mouth. — The maintenance of cleanliness of the mouth is important. 
It may be wiped out with soft lint or cotton moistened with 2 per cent 
boric acid solution, but we must avoid washing out the mouth directly after 
a nursing, to prevent vomiting of recently ingested milk. The mouth of 
infants is exquisitely tender, and cleansing with the finger, unless carefully 
done, is apt to injure the epithelial surface and result in ulceration. The 
same injury occasionally results from the pressure of too large a rubber 
nipple. Ulcerative stomatitis in the new-born is observed over the ham- 
ular process of the sphenoid, and is due to irritation in cleansing the mouth 
or may be due to the irritation of epithelial pearls in the roof of the mouth. 
It shows as a superficial ulcer, covered with a yellow film and bounded 
by a red line, and may occupy the larger part of the soft palate. Such 
a child appears in good health and has no fever. The epithelial pearls 
are a physiological formation and require no treatment, as they disappear 
in time. The stomatitis yields to the usual local antiseptic treatment. 

The Eyes. — Avoid the use of a sponge to the eyes. Fresh tufts of ab- 
sorbent cotton are cleanlier and less irritating. To prevent the occurrence 
of ophthalmia neonatorum, instil a ^ to 2 per cent nitrate of silver 
solution into the eye and neutralize after a few minutes with mild sodium 
chloride solution (table salt). 

The Temperature at birth is about 100° F. This soon falls, and varies 
from a fraction to a degree under the action of the bath, clothing, and 
skin radiation. The average rectal temperature of the healthy infant is 
about 99°. 

Respiration in infants is diaphragmatic, and the rhythm is easily dis- 
turbed. At birth we observe 35 to 40 respirations a minute. 

Pulse. — At birth it is quite rapid, more so in the female than in the male 
infant. In infancy, too, the slightest disturbance in activity from rest to 
motion profoundly influences the pulse rate and its force. The average 
frequency of the pulse is about 120 to 150. 



POINTS TO BE OBSERVED BY xNURSES 



89 



Weight. — At birth it varies, the average weight being about seven 
pounds. During the first few days after birth there is a sUght loss in weight 
and then a gain of about half an ounce daily. The average gain in weight 
for the first two years is about 20 pounds, in length about 10 inches. 

The Stools. — The color of the first stool (meconium) is black. Normal 
stools are yellow and like mush. Curdy and green stools and loose 
watery stools indicate some form of indigestion. 

Clothing. — The clothing should be of such texture and structure as 
to insure everything that the terms comfort and hygiene comprehend. 
Avoid the use of tight and constricting bands at the waist. The flannel 
band should be about four inches wide, without hem, and applied smoothly 
twice around the body. For diapers soft cotton napkins one yard by one 
half yard, folded once, are suitable. Rubber outer diapers have their 
advantages for purposes of cleanliness, but should be worn only on occa- 
sions of outing, when the conditions are such that fresh diapers cannot be 
applied. 

The stockings should be secured to the diapers. The outer garments 
of the infant should not be too long and they should open in front. 

The Nursery. — Children will not thrive unless they have sunlight and 
unless they sleep in a well ventilated room. During the day the room should 
have a temperature of 68° to 70° F., at night 60°. Under no circumstances 
is a gas stove or oil stove to be used to heat a room unless it is connected 
with a flue so that the products of combustion may escape. The amount 
of air space necessary for a child is from 800 to 1,000 cubic feet, with proper 
facilities for ventilation. The child, after three weeks have elapsed, is to be 
taken out of doors daily in clement weather, to enjoy the beneficial effects 
that sunlight and fresh air conduce to. At the sixth month the baby is 
to be vaccinated. Babies attempt to sit up about the sixteenth week and 
try to stand about the ninth or tenth month. The first milk teeth come 
about the seventh month, and the permanent teeth about the seventh year. 

Nursery Requisites. — Bath tub; rice powder and pepperbox; wash 
cloths (no sponges) ; alcohol lamp for warming purposes ; hot water bag ; 
fountain or piston syringe with soft rectal tube; absorbent cotton for the 
eyes; fennel tea; white vaseline. 

Bathing Infants. — A daily bath should be given at about 95° to 99° F, 
in a warm room. As children grow to one year, the bath water may have 
a temperature of 90° — for older children 70°. During warm weather one 
bath night and morning is necessary, or one warm bath and a cool sponge. 
The bath should be of short duration, followed by mild friction when the 
child is out of the water. 



POINTS TO BE OBSERVED BY NURSES 

Regular Habits must be established by feeding at regular intervals and 
by putting the child to sleep at the same time of the day or evening. 

Wakefulness is principally caused by overfeeding, night-feeding, thirst, 
or constipation. 

Napkins, not properly washed and dried, will hold urinary salts and 
produce excoriations. In handling a baby the head and neck must be sup- 



90 



PAEDIATRICS 



ported, and in feeding a child from the bottle an overflow of milk must be 
avoided by feeding in a semirecumbent posture and by careful watching. 

Salt water (a teaspoonful to a pint) is useful for the purpose of keeping 
the nose clean and moist. A few drops may be put into each nostril by 
means of a blunt spoon. 

Premature Infants. — Prognosis: Few infants born before the twenty- 
ninth week are saved. Continued loss of weight is discouraging, and the 
sooner a steady gain in weight is recorded the better. 

Treatment. — Premature children require great care and attention, 
and if too feeble to take the breast can receive the mother's milk removed 
with the breast pump from a spoon, or pipette, or by means of the breast 
bottle. Regular and proper feeding, preservation of the bodily heat, and 
great attention to cleanliness must be observed. Simple prematurity is 
oftentimes accentuated by constitutional debility of the child, owing to 
cachexia of the mother from tuberculosis, syphilis, carcinoma, malaria. 





Faulty way. Correct way. 

Fig. 36. — How to Hold the Baby. 
(From Health Culture.) 

Bright 's disease, and other acute diseases, such as typhoid fever and 
pneumonia, or persistent vomiting. If premature children are to thrive in 
an incubator, this apparatus must be connected with the outer or fresh air; 
and they must have incessant care and attention. According to the 
writer's experience premature infants can be raised and do better with- 
out an incubator, if kept in a room at about 80° F., their heat sustained 
by wrapping in cotton batting. 

In cases of prematurity, the mother's milk is inferior to the milk of a 
wet-nurse, whose infant must be healthy, full term, two weeks of age. Pre- 
mature infants if deprived of the breast are fed on low strength top milk 
(J) by means of a medicine dropper. They take from 5j to 5j about 
every two hours and should be fed slowly (see also infant feeding). 

The mother's breasts in the mean time should be pumped and massaged 
so that they will not dry up. The feeding is accomplished by means of a 
pipette. Asses' milk has been successfully tried in feeding premature 
infants. 



PREMATURE INFANTS 



91 





|IUll.U<IIUJIfl|k. 

InHl^iaKitiwiii 

lAUUiiiiiiainiMuii 



When there is an attack of cyanosis in a premature infant, the child 
should be inverted in order to clear the trachea; and a few drops of diluted 
whiskey may be given. Attacks of cyanosis are not necessarily fatal. 
The bowels should be made to move. Some hardy individuals can be raised 
artificially altogether. Infants of three and a half to four pounds can be 
saved at six and a half to seven 
months. A seven months' infant 
would require one half ounce of 
modified milk every hour and a half. 

The Nipples of the Mother should 
be attended to weeks before parturi- 
tion. They are to be drawn out 
occasionally and made pliable with 
cold cream to prevent subsequent 
retraction. After nursing, the nip- 
ple should be washed with boric acid 
solution. In the event of fissured 
nipple developing, associated with 
much pain in nursing, it is wise to 
draw milk with a breast pump and 
feed the child with a spoon or 
directly from a breast bottle. The 
fissure may be cauterized with 5 per 
cent nitrate of silver solution, after 
which a mild protecting salve of 
bismuth, zinc oxide, or aristol may 
be applied. The nipples may also 
be painted several times a day with 
the white of egg. 

Pus in the Breast of the Mother; 
Mastitis; Caking. — When the breast 
becomes tender and before it is ac- 
tually in a state of inflammation, a 
supporting binder should be applied 
and a dose of salts administered. 
In the event of suppuration nursing 
must cease. Milk should be re- 
moved artificially from the breast by 
the use of a breast pump. Suppura- 
tive mastitis is a surgical condition 
and demands operative interference. 

In the new-born we meet fre- 
quently with a condition of mastitis 

usually brought about by meddlesome interference with the infant's nipple 
in attempts to squeeze out secretion. Such cases as a rule are of simple 
inflammatory type and respond in a few days to moist compress treatment. 

If inflammation of the mother's breast goes on to the formation of an 
abscess, incision is necessary. The incisions are to be made radiating 
from the areola to the breast periphery, and all pockets collectively and 




Fig. 



37. — Incubator for 
Children. 



Premature 



92 



PAEDIATRICS 



individually broken up. Sufficient and thorough drainage must be estab- 
lished with suitable drainage tubes. No region of an extensively involved 
mammary gland should be left unexplored by the finger, or the operation 
has been incompletely performed, thus necessitating a second and perhaps 
a third narcosis, additional surgical interference, with the associated depress- 
ing influences, and ultimate unsatisfactory results. The operation as 
above indicated is the only radical, rational, and correct practical method 
of satisfactorily attacking and treating the condition. Appropriate sterile 
dressing should be applied over the operative area and changed alternately 
for a few days, and at each change irrigation should be practised to insure 
patency of all the tubes inserted and to keep up the desirable thorough 
drainage. With the gradual closure of the drained areas, the tubes are 
removed and the wounds treated on general surgical principles of cleanliness 
until healing is complete. 



WHEN CHILDREN BEGIN TO WALK 

The following table records experiments upon 1,220 children and gives 
the age at which they commenced to walk, and should be of interest to 
young mothers: 



Age. 



No. of Children. 



Per Cent. 



8 months 

9 months and under 

10 months and under 

11 months and under 

12 months and under 

13 months and under 

14 months and under 

15 months and under 

16 months and under 

17 months and under 

18 months and under 

19 months and under 

20 months and under 

21 months and under 

22 months and under 

23 months and under 

24 months and under 



3 

53 

120 

213 

393 

520 

680 

803 

886 

941 

1,048 

1,073 

1,098 

1,106 

1,128 

1,135 

1,165 



0.2 
4.3 
9.8 
17.5 
32.2 
42.6 
55.7 
65.8 
72.6 
77.1 
85.9 
88.0 
90.0 
90.7 
92.5 
93.0 
95.5 



DISEASES OF THE NEW-BORN 

Constipation. — This is to be remedied by soap water enemata, using a 
soft rubber rectal tube for insertion or by soap suppositories. If avoidable 
do not resort to drugs to overcome constipation. Increase the percentage 
of fat in the food and give water. Gentle massage of the abdomen once a 
day is efficacious. 

Jaundice very frequently appears in the first few days of infant life. 
As a rule it is transient, although it may persist for several weeks. Its 
presence is usually of no consequence, and frequently warm baths alone are 
efficient in dissipating the condition. When constipation is a factor, small 
quantities of Vichy water may be administered, a teaspoonful at a time. 
Infectious jaundice (Winckel's disease) is a grave condition. It is looked 



DISEASES OF THE NEW-BORN 93 

upon as an infectious epidemic hsemoglobinuria of the new-born, with 
cyanosis and jaundice, the jaundice and nervous symptoms occurring in the 
first week of Hfe and ending fatally in coma and convulsions in pronounced 
cases. In the absence of definite knowledge on the subject, the manage- 
ment of this symptom complex will be symptomatic. 

Colic. — The most frequent cause is overfeeding, and the majority of 
instances must be attributed to this factor. To overcome colicky attacks, 
regulate the time and quantity of feeding. As therapeutic agents, use warm 
baths, soap water enemas, warm mint tea, and rarely paregoric in five drop 
doses to counteract pain. 

Renal Colic in Infants. — Uric acid infarctions are frequent in new-born 
infants. Gravel-stone and calcareous deposits are not infrequent. Gravel 
is often found in diapers. In such cases an abundance of water should be 
supplied to the infant. 

Snuffles. — " Snuffles " in the infant is not always to be looked upon as 
syphilitic. Very frequently it is due to uncleanliness, and as a result a 
catarrhal condition is established. Treat by instilling salt water with a 
pipette into the nostrils and anoint the alee of the nose with oil or lanolin 
or vaseline to prevent excoriation and crusts. Adenoid tissue may be 
removed by scraping with the finger nail. 

Crowing Sounds and Congenital Stridor. — The majority of crowing 
sounds take their origin in the nasopharynx or larynx, and disappear when 
the children are older. A soft catheter should be passed through the nostrils 
to make sure of the absence of occlusion. Crowing sounds with and without 
stridor have been observed in cases of catarrhal laryngitis, spasm, paralysi;: 
and papilloma of the larynx, atelectasis of the lung, syphilitic broncho- 
stenosis, retropharyngeal abscess, adenoid vegetations, enlarged thymus 
gland, congenital deformity of the superior laryngeal aperture, etc. Oc- 
casionally there is an obstetrical laryngitis due to aspiration of septic 
material by premature respiration on the part of the child in the course of 
a slow labor. In some cases it is only manifested on exertion. 

Prognosis. — In weakly children the condition may prove fatal. As 
a rule it passes off before the end of the second year. 

Treatment. — A general tonic treatment or antisyphilitic regime is 
called for. The nasopharynx should be kept clean, and adenoids, if present, 
should be removed by scraping with the finger nail. 

Ocular HaBmorrhages in the New-bom. — Long and complicated labors 
naturally predispose to the occurrence of intraocular haemorrhage. Ex- 
travasations are most likely in congenitally weak children, and in those 
with a family history of hsemophilia. 

Atelectasis : Respiratory failure. — Congenital atelectasis is a persistence 
of the foetal state in any part or the whole of the lung, and is associated 
with asphyxia of the new-born; but it may occur in feeble and premature 
infants without asphyxia. Such infants show evidence of malnutrition 
and have attacks of cyanosis ending in death or recovery after repeated 
attacks. When one lung is affected, we get a difference in percussion note 
and feeble respiratory murmur, occasionally rales. 

Treatment. — The newly born should be made to cry, whether as- 
phyxiated or not, in order to promote expansion of the lungs. Artificial 



94 PAEDIATRICS 

respiration, as described under Asphyxia, and warm baths with friction 
may also be necessary. 

The Breasts of the Infant. — The breasts of the infant may swell and 
become inflamed. They sometimes contain jnilk, and undue handling of 
the breast or prolonged attempts to express the milk are occasionally 
responsible for infantile mastitis. When fluctuation shows pus to be present, 
an incision is indicated. 

Angeioma of the breast is occasionally observed in infants and requires 
surgical treatment. 

Excoriations and Erythema are frequently caused by the irritation of 
dirty linen, and are most frequently situated in the flexed portions of the 
limbs, the neck, the buttocks, and the perineal region. Soiled napkins 
which have been insufficiently washed contain, when dry, urinary deposits 
which act as irritants. Rice powder, starch, cold cream, zinc ointment, 
and tallow are therapeutic agents of relief. 

Pemphigus vulgaris (non-syphiliticus) is frequently observed in infants 
and runs a mild course, with but little fever, of about two to three weeks. 
The blebs contain serum which becomes turbid. It seems to be contagious 
and has a tendency to spread among children in institutions. Cleanliness 
is the best treatment. A protecting ointment of bismuth and ichthyol is 
necessary to cover the excoriated skin. Stearate of zinc powder may be 
dusted on the blebs and raw surfaces. Of course the general condition 
requires attention, and if syphilis is suspected as the underlying cause, 
specific treatment must be employed. The skin lesions of congenital 
syphilis will be discussed under Syphilis. 

General Seborrhoea Sicca (Squamosa Neonatorum); Ichthyosis Se- 
bacea. — The body is covered with reddish brown scales, and the skin is 
dry and shows painful fissures. If general it is usually fatal in new-born 
children. 

Treatment. — Lanolin and ichthyol, 5 per cent. Try thyreoid treat- 
ment internally. 

Congenital Ichthyosis (Grave Form). — The skin looks like furrowed 
parchment, the nostrils and ears are occluded by epithelial debris, and the 
skin feels hard and cracks or splits. The prognosis is bad. In mild forms 
life may be prolonged for years. 

Treatment. — Cleanliness, baths, inunction with pure oil. Attention 
to the bowels. Lanolin and ichthyol, 5 per cent to 10 per cent. Try 
thyreoid treatment internally. 

Sclerema and (Edema. — Both of these conditions may be congenital. 
The exact setiological factors are not definitely known, although in oedema 
a poor, weak, disturbed circulation is a factor as well as symptom. The 
treatment is to be chiefly directed toward establishing better conditions 
of nutrition and appropriate stimulation. In sclerema the skin is hard and 
indurated as opposed to the softer, non-resistant feel observed in oedema. 
A subnormal temperature is present in sclerema, and the indications there- 
fore are for the establishment of normal temperature by appropriate clothing, 
bathing, friction, and stimulation. The prognosis in sclerema is unfavor- 
able. Possibly the administration of thyreoid extract may favorably 
influence the course. 



DISEASES OF THE NEW-BORN 95 

(Edema may be confounded with sclerema. It begins soon after birth 
(also in premature infants), usually at the feet, and successively invades 
the whole body, particularly the extremities, the scrotum, and the labia. 
The oedematous parts are cold and pit on pressure. When the whole 
body is affected, the child's respiration is impaired, the pulse is slow, the 
temperature is subnormal, and the child is drowsy and dies. 

Prognosis, — In complete oedema this is bad; in partial cedema, fair. 

Treatment. — Hot water bags ; wrap in cotton batting; general 
massage; proper feeding (higher percentage of proteids); camphor to 
stimulate the heart; five to ten drops of camphorated oil subcutaneously 
twice daily. 

Birth Marks: Naevi, Telangeiectas'.s, Angeioma (Superficial and Cav- 
ernous). — There are three varieties of nsevi in young children — superficial 
naevi, which disappear in time and do not require treatment, and superficial 
and cavernous naevi, which require surgical interference. Superficial naevi 
may be destroyed by the electrolytic process. The needle is connected 
by means of a needle holder with the negative pole of a galvanic battery 
and the current closed by means of a sponge electrode held in the patient's 
hand, A current of only a few milliamperes is used. The current is broken 
by removing the sponge electrode. This is the same process employed for 
the permanent destruction of hair by electrolysis. The actual cautery, 
galvanic or Paquelin, is the most satisfactory means of destroying naevi. 
The part to be destroyed is cleansed with green soap and alcohol, and 
punctured in many places with the red hot needle point. Iodoform is 
dusted on the destroyed skin and a dry scab is allowed to form and eventu- 
ally to fall off. One thorough treatment is usually all that is necessary. 
In case the vascular new growth has not been entirely destroyed by the 
cautery, a second application will be necessary. A cavernous angeioma 
is a strictly surgical affair and is best eradicated by the knife. 

Umbilicus. — The stump of the cord is frequently the portal of entrance 
of infectious disease. Tetanus and erysipelas are examples. Eczema of 
the umbilicus is of common occurrence and responds to bismuth and zinc 
ointments. Keep the part dry and clean. Polypus, or granuloma, is re- 
moved mechanically by twisting the pedicle or by ligature or cauterization. 
Omphalitis involving the neighboring abdominal tissues may go on to 
suppuration and gangrene and spread over a considerable area. If an 
abscess forms, incision and drainage are indicated. In umbilical sepsis 
of the new-born there is usually fever and there may be purpura or petechia. 
There may be bleeding from the vagina and nose, vomiting, and muscular 
rigidity. This symptom complex is characteristic and enables us to dis- 
tinguish such cases from haemophilia. Pronounced cases are fatal. We 
must look to the future for an antitoxine for this form of sepsis, which may 
be avoided by proper management of the cord. 

Tetanus. — This is an acute specific infection. It sets in at about the 
fourth or fifth day. The portal of entrance is the stump of the cord. 
In nursing, the jaw becomes rigid and the face drawn. The body of 
the child becomes stiff and in the intervals relaxed. Fever sets in and 
death takes place from exhaustion or asphyxia. The mortality is about 
90 per cent. 



96 PEDIATRICS 

Treatment. — Tetanus antitoxine should be administered, together 
with small doses of chloral hydrate (about half a grain) and bromide of 
potassium (about one grain), every two to three hours. Also use warm 
baths at 95° F., with mild massage and proper feeding. Obstetrical cleanli- 
ness prevents tetanus infection. 

Trismus. — Mild cases of tetanus have been termed trismus. The exact 
relation between trismus and tetanus is not known, but it is a fact that many 
cases of so called trismus get well under hygienic management and the 
administration of bromide and chloral. 

Fatty Degeneration (Buhl's Disease) is an acute fatty degeneration of 
the viscera — (heart, lungs, liver, and kidneys) — with a tendency to haemor- 
rhage, no special rise of temperature, and early death from asthenia or acute 
ha3morrhage, probably due to infection. The treatment is symptomatic. 

Congenital Rigidity (Little's Disease). — A congenital rigidity of the lower 
extremities, probably due to syphilis, is known under this name and may 
necessitate symptomatic and specific management. 

Haemorrhagic Disease. — Not all cases of hsemorrhagic disease are due 
to haemophilia, which is rarely manifested before the end of the first year. 
On the other hand, infants known to bleed during the first days of life 
recover and are not apt to bleed in after life. The hsemorrhagic phenomena 
which are associated with various forms of umbilical sepsis are mentioned 
elsewhere. 

Umbilical Haemorrhage. — Bleeding from the cord or navel wound may 
be due to negligence in tying the cord. The writer has met with a few cases 
of severe haemorrhage from the navel cord on the third to the fifth day. A 
haemorrhagic state, or dyscrasia from congenital syphilis or from intestinal 
putrefaction and toxaemia of the mother, may be the causative factor. 

Treatment. — Apply strong alum water. Ten per cent solutions of 
antipyrine and adrenalin solution are powerful local styptics. If they 
fail to check the haemorrhage, the skin should be transfixed with needles 
and pressure exerted by means of a silk suture wound around and under- 
neath the pins, Stypticin may be given internally in half grain doses, or 
injected hypodermically, dissolved in water. A single bleeding point may 
be touched with the actual cautery. 

Gastrointestinal haemorrhage may set in at any time during the first 
week after birth. The blood comes from the stomach and bowels in smaller 
or larger quantities, usually in dark masses. It may be due to: (a) Syph- 
ilis, sepsis, hcemophilia, etc.; (b) Local ulceration in the gastrointestinal tract; 
(c) Injury related or not related to labor. In most of the cases observed by 
the writer the infants appeared healthy and were of healthy parentage. 
The children usually die within one half to two days, but occasionally re- 
cover. The heart's action is generally very rapid, and finally the pulse is 
no longer felt. If the blood coagulates in the stomach, vomiting expels it. 
The PROGNOSIS is unfavorable. 

Treatment. — Careful and judicious feeding and stimulation. If 
the infant cannot suck, give the mother's milk from a spoon. Enjoin per- 
fect rest and apply ice to the stomach and hot water bags to the surface. 
Adrenalin solution, gtt. 5, or an aqueous solution of suprarenal extract 
(Gr. V to 3j), dose 10 gtt., may be given every half hour. Alum water, 



DISEASES OF THE NEW-BORN 97 

1-20, may be used internally, in doses of ten drops, also as an enema. Styp- 
ticin, gr. ^ internally every hour, is useful. Two to four drachms of a 
sterile solution of gelatin may be injected subcutaneously or may be given 
by mouth or per rectum. 

Intussusception. — This is rare in the new-born, but of considerable fre- 
quency in early infancy. The symptoms are not pathognomonic, although 
vomiting, tenesmus, and mucus and blood in the stools suggest the pos- 
sibility of the condition. Abdominal palpation frequently reveals the 
presence of a tumor. Rectal palpation often establishes the diagnosis 
where other manipulations and symptoms fail to indicate the trouble. 
The introduction of water under moderate pressure into the rectum may 
effect the desired reduction of the tumor. Where this simple procedure 
fails, operative interference is indicated. Moreover, in these cases surgical 
interference should be prompt, as delay is hazardous. 

Umbilical Hernia. — This, as a rule, is readily reducible, and frequently 
recovery is spontaneous. A small button-shaped pad is laid over the 
umbilicus after reducing the hernia, and a strip of adhesive plaster applied 
to keep the pad in situ. Specially constructed pads and appliances are now 
to be had in the shops for this class of cases. 

Inguinal Hernia, where reducible, may be kept in place by applying a 
truss or by adjusting a worsted skein with the knot over the seat of hernial 
protrusion. In the reduction of hernia care must be exercised in the 
manipulation; an irreducible hernia demands surgical interference. Do 
not confound inguinal hernia with hydrocele. The former is translucent 
to transmitted light — the latter opaque. 

Operation for Hernia in Children. — Aa operation is seldom ad- 
vised under the age of four years except in strangulated cases. The reason 
for this rule is that many of these cases, probably two thirds, are cured by 
a truss. After the age of four years, in all cases in which a truss has been 
tried and failed, and in cases in which the presence of reducible hydrocele 
prevents a truss from holding the rupture, an operation is advised. The 
same rules hold good in irreducible omentum, a rare condition in childhood. 

Caput Succedaneum is the swelling which appears on the scalp intra 
partu. It disappears in due time and requires no treatment. 

External Cephalaematoma. — These swellings are due to blood extravasa- 
tions between the skull and pericranium, and most frequently are of trau- 
matic origin, caused by undue forceps pressure, prolonged labor, or mal- 
position with difficult delivery. They usually make their appearance a 
few days after birth, gradually enlarge, and are soft and fluctuating to the 
touch. Generally there are no associated evidences of inflammation, 
and the recovery is spontaneous, absorption taking place in four to sixteen 
weeks. Should infection and consequent abscess formation ensue, incision 
and drainage on antiseptic principles constitute the proper treatment. 

Internal Cephalsematoma. — This is a haemorrhage between the dura 
mater and the cranium, and may lead to all the manifestations of intracranial 
haemorrhage (apoplexy), viz. convulsions, paralysis, meningitis, and cystic 
degeneration, with recovery, idiocy, or death. An external hgematoma 
may extend through a cranial fissure or fracture to the cranial cavity. 
The treatment is usually expectant, in the hope of spontaneous absorp- 
8 



98 PAEDIATRICS 

tion of the extravasation. Intracranial surgery has its limitations in the 
new-born. 

HaBmatoma of the Sternocleidomastoid is a firm, hard tumor of traumatic 
origin in the tract of the muscle. It disappears in time and requires no 
treatment except mild massage. 

Meningocele and Encephalocele are terms used to designate the pro- 
trusion of some part of the cranial contents through an opening in the skull. 
These conditions are analogous to spina bifida. 

Meningocele is a protrusion of a portion of the arachnoid fluid with its 
sac through one of the cranial openings and communicating with the arach- 
noid cavity. It is smooth, fluctuating, perfectly translucent, rarely pul- 
sating, and often reducible. Occasionally we meet with a meningocele in 
the nasofrontal region. The treatment by aspiration and injection with 
iodine is sometimes satisfactory and followed by permanent recovery, but 
not always so. Marked reaction has followed operative procedure, and 
death from meningitis has taken place. An operation is justifiable in cases 
of impending rupture. 

Spurious meningocele from traumatic fissure of the cranium and dura 
is occasionally observed. The tumors are translucent, elastic, and generally 
small, and require no special treatment. If a differential diagnosis between 
hsematoma and meningocele must be made, an aseptic aspiration can be 
done. The elevation of a depressed bone may be indicated when epileptic 
seizures occur. 

In ENCEPHALOCELE the tumor is smooth, rarely pedunculated, and 
not translucent, and does not fluctuate. It contains meninges, fluid, and 
brain substance. Encephalocele is not to be confounded with hsematoma. 




I'll.. oN. J ;.\( l.l'HALOC'KLE. 

Vault of cranium absent. Age one year. (H. Fischer.) 

In the former the swelling is situated at the fontanelles, or along the cranial 
sutures. Encephalocele increases and varies in size with the movements of 
respiration, and is often accompanied by cerebral symptoms. The treat- 
ment is by compression. The most pronounced case of this kind is one seen in 
consultation with Dr. H. Fischer, of New York. As shown in Figs. 38 and 39, 



DISEASES OF THE NEW-BORN 99 

the top of the skull is absent and the brain is prolapsed into a sac formed 
by the scalp, and lies outside of the cranial cavity. At the age of six months 
the child was under the knife in one of our city hospitals, where the actual 
condition was not recognized. When the sac was opened and the brain 
presented itself, the surgeon saw his mistake and beat a retreat. The child 




ilG. 39. E-NCKPHALOCKLK AT TlIKKJ:; VkaK.S. 



at the present time is four years old and in good health, excepting occasional 
epileptoid attacks. 

Chondrodystrophy fcetalis is, as its name implies, a faulty development 
of cartilage resulting in deformity. The causative factors of this condition 
are unknown. 

Stunted growth (achondroplasia) was formerly spoken of as foetal rickets 
or foetal cretinism. It differs from cretinism in the absence of the mental 
defects which characterize the cretin. There are two features in the limb 
bones which suggest, at first sight, a similarity to rickets. The one is cur- 
vature of the shafts, the other a prominence of the terminal epiphyses. But 
the bending in the case in question is not due to softness of the bones, as 
in rickets; on the contrary, the bones are quite firm and rigid. Moreover, 
there is no actual enlargement of the terminal epiphyses. The knobbed 
appearance in this case is explained by relative smallness of the shafts. 
In achondroplasia the bones resulting from ossification in membrane are 
formed as usual, but the parts which are ossified in cartilage in early foetal 
life are stunted in their development, as if from premature arrest of the 
ossifying process, and hence the defect in the long bones of the limbs, the 
ribs, the pelvis, and the greater part of the base of the skull and the con- 
comitant disfigurement of the skull and upper portion of the face. In 
most instances it would appear that the foetus, when the subject of achon- 
droplasia, either dies in utero or shortly after birth. Only a few patients 
have grown into childhood. 

Congenital Lipoma is an elastic, non-compressible tumor found any- 
where on the surface. It may disappear or persist, and need not be inter- 
fered with unless it gives rise to local disturbance or discomfort. 

Congenital Hygroma and Cysts. — These occur on various parts of the 
surface. Their accumulation of fluid contents can be removed by a 



100 



PAEDIATRICS 



simple incision. Should the fluid reaccumulate, the subcutaneous sac 
must be enucleated in toto under anaesthesia. Congenital cysts of the 
kidney are occasionally observed. 

Congenital Hydrocele. — The diagnosis of encysted hydrocele of the cord, 
hernia, and undescended testicle is sometimes difficult. A congenital 
hydrocele often disappears after a few weeks. 

Congenital Malformation of the Heart (blue babies). — Such ailments 
are of little practical importance; the children so afflicted frequently suc- 




Dwarf. 

Fig. 40. — Achondroplasia. 



Norniul. 



cumb to some intercurrent disease. Cases which at birth give evidence! 
of a systolic murmur, which ultimately disappears, may be cases of per- 
sistence of the ductus arteriosus, which sometimes closes spontaneousl3% [ 
In blue babies with patency of the foramen ovale we may and may not 
hear a murmur. There is no active treatment for any of these cases. In 
some instances, owing to a profound disturbance of the circulation, the 



DISEASES OF THE NEW-BORN 



101 



suffering is so intense as to warrant the use of opiates or chloral hydrate 
at night. 

Enlarged Thymus Gland. — This condition may give rise to heart murmurs, 
respiratory stridor, and sudden death, as illustrated by the following case: 
An infant six weeks old was observed to be restless with spells of rapid 
breathing, A careful examination revealed a loud systolic murmur at the 
base of the heart which was not transmitted in any direction and which 
did not take the place of the systolic click of the valves. The heart dul- 
ness extended upward and laterally beyond the normal. The baby had one 
or two convulsions, from which it rallied promptly. It died very suddenly 



1 


P 


t 


. > 


1 


m 




1 
j 

1^ ' 


m 


Wt^^ 


W^. ■■' 1 


r 


'A 


#/ i 


^^^^Bl^ \^ 


r 


m 


ri^BBi 


^^^l^^^k '^ ^ v^^^B^ 


j 








j 



Fig. 41. — Enlarged Thymus. (Dr. Cox.) 



without premonitory signs. At the autopsy the heart was found to be 
intact, the ductus arteriosus was closed, and the thymus gland was very 
large and so located as to encroach by pressure upon the lumen of the aortic 
arch and pulmonary artery. It may be of practical importance to know 
that the enlarged thymus gland may be recognized by percussion upward 
as the child is held face downward. The removal or high fixation of an 
enlarged thymus gland is a surgical possibility. See also article on the 
Thymus. 

Birth Palsies. — These in a majority of instances are the result of pressure 
or injury induced by artificial delivery (with forceps), or in prolonged labor 
from undue pressure by the maternal parts. In difficult labor (breech 
presentations) the parts involved are usually one or more of the extremities, 
Erb's paralysis being a familiar type in which the upper arm is involved. 
Facial palsies due to pressure of the forceps on the facial nerve are not of 



102 



PAEDIATRICS 



rare occurrence. Forceps neuritis of the neck is another form. Cerebral 
PALSY, a result of haemorrhage at the base of the brain, is still another 
form. The treatment of the types commonly met with is by faradism, 
galvanism, vibration, and massage. In instances where injury to the nerve 
supply is extensive and no response to treatment ensues after a few weeks, 
permanent paralysis with accompanying atrophy of the muscles supplied 
ensues, and the use of the limb is impaired. Nerve suture and nerve 
anastomosis are surgical possibilities (see also Neurological Memoranda). 



DEFORMITIES; MALFORMATIONS 

Common Forms 

Hare lip and cleft palate are among the most frequent of congenital 
deformities. Their treatment is strictly surgical, but operative interference 
should not be resorted to at too early a period. It is wise to wait until 
the child acquires a little vigor and is better able to withstand operative 
measures. Meanwhile the mouth, nose, and throat should be kept scrupu- 
lously clean. If the infant cannot nurse well as a result of the deformity, 

it may be necessary to temporarily feed it 
artificially by means of a specially con- 
structed nipple with a rubber flap at- 
tachment which adapts itself by the 
suction to the opening in the palate. 

Imperforate anus and rectal stenosis 
demand early relief. The simple variety 
of cutaneous anal atresia is easily reme- 
died by simple incision and digital dila- 
tion. Atresiae higher up in the rectum 
require skilful dissection by the surgeon. 
Atresia of the rectum with communication 
between rectum and vagina is occasion- 
ally found. In such cases the faecal mat- 
ter escapes through the vulva. If there 
is no obstruction to the passage of faeces, 
operative interference should be delayed 
until the parts are large and more de- 
veloped. 

Tongue tie exists more in the imagi- 
nation of the mother of a child than in 
fact. Whenever the frenum of the tongue 
is too short, put the tongue on the stretch 
by inserting two fingers into the mouth 
under the tongue, and cut the frenum with blunt scissors while it is on 
the stretch. Bifid tongue and bifid uvula are occasionally met with. 

Spina Bifida. — This is a not uncommon malformation of the spinal 
canal with a cystlike protrusion of its contents — cerebrospinal fluid. The 
elastic and compressible tumor may be simply a meningocele (membrane 
and fluid) or meningomyelocele (membrane, cord, and fluid). Spina bifida 




Fig. 42. — Spix.\ Bifida. 






CONGENITAL DEFORMITIES ; MALFORMATIONS 



103 



is readily recognized, but it is occasionally difficult to tell which variety 
we have to deal with. The simple spina bifida frequently heals spontane- 
ously. The bony aperture closes and the cystic sac dries up. Under all cir- 
cumstances the tumor must be kept clean and protected by cotton batting. 
Simple aspiration and compression 
are usually of no avail. When there 
is no danger of rupture, operative 
interference is not urgent and may 
be deferred until the child is older. 
Aspiration and injection of iodine 
solution is a procedure not free from 
danger. Ligature and excision of 
the sac is a safe operation. Plastic 
operations with an attempt at clo- 
sure of the aperture by flaps of 
neighboring periosteum have been 
attempted with varying success. 
In the worst cases there is paralysis 
of the bladder and rectum. 

Hypospadias. — In this condition 
the urethra opens on the inferior 
surface of the penis. In front there 
is only a shallow furrow. In severe 
cases there is a deep fissure w'hich 
divides the scrotum, and when in ad- 
dition the testicles are undescended, 
the case is erroneously taken for 
hermaphroditism. 

Epispadias. — The urethra opens 
on the dorsal side of the penis, and 
the condition may be complicated 
by exstrophy of the bladder. An 
analogous deformity is met with in girls. All these deformities are com- 
patible with long life, and can be removed in many cases by a plastic 
operation. 

Cryptorchidism, or undescended testicle. In foetal life the testicles 
are situated in the abdominal cavity, below the kidneys. In about 10 per 
cent of all children they fail to descend into the scrotum at full term, but 
come down during the first few weeks of life. When one remains in the 
inguinal canal, it should be let alone unless very painful, when it should be 
removed, or better, an attempt should be made to put it into its proper 
place. 

Phimosis. — This condition is frequently met with and varies in degree. 
Where there is simply a short prepuce with moderate epithelial adhesions, 
the condition may be corrected by stretching. When the prepuce is long, 
and stretching will not remedy it, circumcision is resorted to; but this 
operative procedure msiy be delayed until about the ninth month if there 
is no difficulty in micturition. The method is as follows: Under general 
ansesthesis the prepuce is drawn forward, placed between the blades of a 




Fig. 43. 



-Thokaco Abdomino Pagus. 
(Dr. Sheffield.) 



104 



PiEDIATRICS 



narrow artery forceps, and the presenting portion snipped off with scissors. 

On removing the forceps, the redundant inner (or mucous) layer presents 

itself, which is removed in the same 
way, and a few sutures of black silk 
are inserted in such a manner that 
the bleeding vessels are also included. 
A mild antiseptic ointment is ap- 
plied, the part placed in suitable 
lint, and the diaper applied. The 
sutures may be removed about the 
fifth day. The object of applying 
black sutures is that they may be 
readily detected when the time for 
their removal arrives. A simpler 
method, very often satisfactory, is 
to cut a short distance into and 
along the dorsal aspect of the pre- 
puce until the glans is exposed, and 
take a stitch in either flap of the 
prepuce so cut and dress aseptically. 
Unrelieved phimosis, on account of 
local irritation, may affect the gen- 
eral health of delicate children. 

Web Fingers and Toes; Super- 
numerary Digits. — These call for 
plastic surgery or extirpation. Club 

foot and other deformities due to undeveloped conditions or as the result 

of intrauterine constricting bands call for special orthopaedic and surgical 

treatment. (See chapter on Orthopaedics.) 




liG. 44.- 



-Thou A(()-AiiD(^MiNO Pagus. 
(Skiagram.) 



Rare Forms 

Atresia Oris; Microstoma. — The lips are grown together entirely or sepa- 
rated by a small opening. This malformation is usually due to syphilis 
and necessitates constitutional treatment and a cheiloplastic operation. 
Atresia pupillae congenita is a rare malformation in which spontaneous 
improvement usually occurs. Atresia of the small intestine is rare. The 
symptoms are early and persistent vomiting. Nothing passes from the 
bowels after the meconium has escaped. Death occurs within a week 
unless operative interference is successful. Atresia urethrae is generally 
epithelial, but occasionally membranous; blunt pressure or an incision will 
overcome the obstruction. Atresia vaginae hymenalis usually escapes ob- 
servation until puberty, and then requires incision and packing. Cloaca 
congenitalis. In the absence of the anus the rectum may end in the blad- 
der, vagina, or urethra. This condition may be remedied by operative 
interference. 

Congenital Hypertrophic Stenosis of the Pylorus and Duodenum. — 
This is a far more frequent affection than is supposed, but the condition 
is not generally recognized, as the symptoms may easily be misinterpreted. 



CONGENITAL DEFORMITIES; MALFORMATIONS 



105 



I 



The essential feature of the morbid anatomy is the thickening of the circular 
muscular fibres of the pylorus or a fibrous thickening. 

Diagnosis. — Vomiting, dilatation of the stomach, and visible gastric 
peristalsis with emaciation are marked features. Dyspeptic symptoms are 
first noticed, and subsequently the dilatation of the stomach and obstinate 
constipation point to an obstruction in the course of the gastroenteric tract, 
but the pyloric tumor is not felt, on account of abdominal tympanites. 
When the stomach contents are siphoned out they are generally found 
to contain bile. In some instances the bowels move tolerably well until 
a few days before death. In the majority of the cases reported the initial 
symptoms were noticed during the first two weeks of life; in one or two 
instances as late as in the third or fourth month. 

Treatment of Congenital Pyloric Stenosis. — The feeding should 
be regulated, and the stomach may be washed with a ^-per-cent solution of 
Carlsbad salt in water. Drugs are useless ; massage may be employed 
and a stomach binder applied. 
If necessary, rectal feeding may 
be employed. In extreme cases 
pyloroplasty is indicated. Digi- 
tal divulsion of the pylorus 
(Loreta's operation) is not feas- 
ible in infants. Before opera- 
tive interference is attempted 
mild forms of Spasmodic Stric- 
ture must he excluded. Muscu- 
lar hypertrophy at the pylorus 
may be secondary to overaction 
of the sphincter, and injudicious 
feeding may be a contributing 
factor to spasm and nervous 
incoordination. 

Bronchocele and a Branchial 
Fistula. — Persistent congenital 
conditions as the result of im- 
perfect closure and development 
of the branchial arch are strictly 
surgical conditions and call for 
surgical interference. 

Congenital Pharyngooeso- 
phageal Stenosis is a very rare 
malformation in which the up- 
per part of the oesophagus at 
its junction with the pharynx 

ends in a blind pouch. A case of this nature was reported to the American 
Pcediatric Society in 1896 by S. S. Adams, M.D., of Washington, D. C. 

Congenital Stenosis of the Larynx is rarely observed. The infants, 
instead of crying, emit a muffled sound. 

Cranial Asymmetry. — This is no unusual occurrence. It is due to ante- 
natal trophoneurotic, rhachitic, or syphilitic disturbances. 




Fig. 45. — Broxchocele. 



106 



PEDIATRICS 



Umbilical Fistula. — The common form is an umbilical conical tumor 
with a fistula at its summit representing the remains of an embryonal forma- 
tion known as the omphalomesenteric duct. These tumors are of various 
sizes, pink in color, with an oozing discharge from the centre. They may 
become obliterated or be cured by ligature. The large tumors of this 
nature require careful surgical dissection. 

Stigmata of degeneration and manifold deformities are observed which 
usually present more of a surgical than medical aspect. The same is true 
of malformations and monsters. 

Wormian Bodies. — When ossification of any of the tabular bones of the 
skull proves al)ortivo, the membranous interval which would be left is 




Fig. 46. — Marked Curve in Little Finger of Mongolian Idiot. (Dr. West.) 



usually filled in by a supernumerary piece of bone. This is developed from 
a separate centre, and gradually extends until it fills the vacant space. 
These supernumerary pieces are called Wormian bones (after Wormius, a 
Copenhagen physician). They are also called, from their usual form, 
ossa triquetra, but they present many variations in situation, number, and 
size. They occasionally occupy the situation of the fontanelles. 

Congenital fissures and gaps are occasionally found in the cranial bones, 
the result of incomplete ossification. They extend from the margin toward 
the middle, and might be mistaken for fractures. In hydrocephalic skulls 
they are most frequent in the frontal bones and in the parietal bones on 
either side of the sagittal suture. 

Maternal Impressions. — Strong impressions of terror, pain, disgust, etc., 
experienced by the mother during pregnancy are supposed to be responsible 



BREAST FEEDING 107 

for bodily defects in the infant, such as hare Hp, cleft palate, club foot, moles, 
strawberr}^ marks, etc., but this has not been proved. Pending a final 
decision on this obscure subject, it may be well to guard a woman during 
pregnancy as much as possible from unpleasant impressions. 

Fractures. — An infant's cry indicative of pain, disability as to motion, 
dimpling of overlying tissues, and swelling of the soft parts, leads to the 
diagnosis of fracture. A displacement shown by the radiograph is conclu- 
sive evidence. Fractures may be antenatal or occur at birth from ab- 
normal conditions present or from traumatism in precipitate or difficult 
labor. The common fractures are those of the humerus, the clavicle, the 
femur, the cranial bones, etc. 

Infant Mortality. — Ten per cent of the new-born are lost from various 
causes before they are one month old. Responsible for this mortality are: 

Maternal causes before and during labor, including protracted labor 
and asphyxia. 

FcETAL CAUSES are antenatal disease and accidents, multiple preg- 
nancy, malposition and excessive size of the child, congenital feebleness 
and prematurity, and convulsive disorders. 

Sudden death of infants is not an infrequent occurrence from manifold 
causes which usually cannot be elicited except through an autopsy. 



INFANT FEEDING 

BREAST FEEDING ; MATERNAL NURSING 

General Considerations 

It may be regarded as axiomatic that every healthy mother should 
nurse her own baby. A mother's milk is the natural food of the infant 
and is more in harmony with the special requirements of the offspring than 
any substitute form of nourishment. This close tie between mother and 
child must not be severed on insufficient grounds. No kind of bottle food 
can compete with the milk from a healthy breast; a perfect substitute 
for the healthy human breast milk is and always will remain an impossibility. 
Infants, how^ever, do not invariably thrive at the breast, and it therefore 
becomes necessary for the intelligent practitioner to acquaint himself with 
the composition of human milk, that he may be able to recognize what ele- 
ments or factors are at fault in a case of infantile indigestion in a breast fed 
child, that the condition may be remedied or that an artificial food may 
be substituted. This must have as its basis, under all circumstances, the 
composition of breast milk. Breast fed children not alone show indigestion 
in its various phases, but not infrequently have rhachitis, scurvy, or cholera 
infantum; and much of the success of the family practitioner will depend 
upon his knowledge of the dietetic management of the breast and bottle 
fed child. 

It will be well to keep in mind a few physiological points in reference to 
the composition of human breast milk and the conditions influencing the 
uniformity of its composition. A good breast secretes from one to three 
pints daily and is emptied in about fifteen minutes. The milk has a 



108 PAEDIATRICS 

specific gravity of about 1.030, and is of the following composition, with 
variations : 



Water 88 per cent 

Solids 12 per cent 



fFat. 
Proteids. 

Sugar. 

Ash. 



The so called "fore milk " consists of about 10 per cent solids and 90 per 
cent water; the " stripping/' of 15 per cent solids and 85 per cent water — 
this difference of 5 per cent in the composition of fore milk and stripping 
it is important to note, as we shall presently see. According to Johannsen, 
the highest percentage of solids is noticed about three p.m. daily; the lowest 
percentage of fat during the night, when it sinks to 1 per cent. 

The average stomach capacity of a healthy infant is about as follows: 

At birth 1 ounce. 

" 2 months 3 ounces. 

" 6 months 6 ounces. 

" 12-14 months 9 ounces. 

The average gain of a healthy infant at the breast is about half an ounce 
a day. 

The stomach capacity of breast fed children in general is less than 
that of artificially fed children. The capacity of a healthy stomach is 
smaller than that of a functionally inefficient stomach. Large capacity 
may be due to a narrow pylorus; large stomachs without pyloric stenosis 
are usually overdistended stomachs. It has been quite conclusively estab- 
lished that very little fluid is absorbed from the stomach; we must as- 
sume, therefore, that in cases in which there is no gastrectasia, the quantity 
of milk frequently taken in excess of the normal stomach capacity is 
never completely retained at one time in the stomach, but oozes through 
the pylorus into the intestine and does not so frequently overtax the 
stomach of otherwise healthy infants as is supposed and feared. On the 
other hand, in motor insufficiency, from ansemia and other causes, over- 
feeding may produce disastrous results and conditions in infants as well 
as in adults. Among the many conditions affecting the composition of 
breast milk we may bear in mind the following: Age of the mother; num- 
ber of pregnancies; nervous iniiuences (epilepsy, convulsions, worry); diet 
of the mother; exercise of the mother; regularity of nursing; menses; acute 
or chronic illness (e. g., tuberculosis, syphilis, nephritis, typhoid, cancer); 
suppuration of the breast — sepsis; cachexia from other chronic or acute febrile 
disease; drugs. 

Hence, as influenced by these factors and conditions, we may have: 
a. Overrich milk; b. Abundant normal milk; c. Scanty normal milk; 
d. Abundant poor milk; e. Scanty poor milk — producing in the infant, 
sooner or later, no gain or loss of weight, colic, no sleep, bad stools, with 
or without fever, incessant crying for food, rhachitis, scurvy, etc. 

Nursing mothers over forty years of age do not have rich milk as a 



BREAST FEEDING 



109 



rule, and the same holds good for mothers who have borne children in rapid 
sequence. The milk of neurotic or emotional mothers is far from normal, 
and is not apt to be influenced very favorably by judicious management. 

The diet and exercise of the nursing mother are of great importance in 
the production of good milk. Liberal feeding and no exercise will frequently 
give an overrich milk with 6 per cent of fat; hard work together with 
poor food is responsible for a very poor milk with less than 1 per cent of 
fat. Irregularity' in nursing makes good milk bad, and frequent nursing 
is found to give a concentrated milk and produce colic in the child; too 
prolonged intervals in nursing are apt to decrease the total solids and 
produce a milk easily digested but not nutritious. A very concentrated 
milk may be nutritious, but is difhcult to digest. 

Acute and chronic illness often occasion bad breast milk, particularly 
such diseases and conditions as tertiary syphilis, nephritis, typhoid, and 
sepsis. The milk from a suppurating breast is not proper food for an 
infant, and it has been alleged that pus taken with the breast milk is 
occasionally responsible for multiple furunculosis in infants. During the 
catamenial period the breast milk changes in composition, inasmuch as 
the fat percentage is low; but, as this period of depression lasts but a few 
days and former conditions are again established, the appearance of the 
menses is not a direct contraindication for the breast. Finally, it is well 
to remember that all secretory and excretory organs of the body are in 
close touch with the general circulation, and powerful drugs are apt to 
exert their effects upon an infant through the medium of a nursing mother. 

The following analysis, taken from Rotch, expresses in percentage the 
various changes in the composition of breast milk: 



Normal. 


Catamenia. 


Starvation. 


■ 
Overrich. 


Neuropathic 

constitution, 

pregnancy, 

diseases. 


Fat 4. 

Sugar 7. 

Casein IJ 


6. 
2i 


1. 

4. 

2i 


5-e 

7. 
3i 


i 

5. 

^ 



Contraindications for Breast Milk. — Tuberculosis, cancer, syphilis, 
epilepsy, any form of sepsis, cachexia from chronic or subacute disease, 
very acute illness, convulsive attacks — all of these conditions are prime 
indications for weaning. In a case of sore nipple without suppuration of 
the gland the milk may be pumped from the breast and fed from a breast 
bottle. 

In case of pregnancy or gradual diminution of the milk supply of the 
mother, it will not be necessary to wean suddenly. If possible, wait for 
the approach of cold weather before taking the child from the breast, 
gradually substitute other food, and have no regard for dentition. When 
the breast supply gives out gradually, it is a very good plan to give half 
breast and half bottle food. The selection of the latter will depend upon 
circumstances. All things being equal, diluted top milk, sterilized in warm 
weather, should be selected (see cow's milk for infant feeding). > 



110 PAEDIATRICS 

How to Influence the Composition of Mother's Milk 

If a child at the breast shows symptoms of dyspepsia and no gain in 
weight, study the conditions affecting the composition of the mother's milk 
as discussed in the foregoing remarks, and if possible determine the 
amounts of fat and proteids in the milk. If the milk is overrich, the 
mother is to be placed upon a plain diet; and the inactive, phlegmatic, 
lazy mother should be made to engage in active exercise (e.g., walking). 
If the milk is poor in the beginning of nursing, appropriate efforts should 
be made to increase the percentage of fat by allowing the mother a liberal 
diet of albuminoids (eggs, meat), and curtailing exercises. Liquids (beer, 
porter) increase the flow of milk, but do not enhance its richness. Fat 
does not increase fat. (See article on Diet.) 

In making an analysis of milk for practical purposes we have to inquire 
into the percentage of fat and casein therein contained. The microscopical 
and specific gravity tests are uncertain and furnish no very definite data. 
The Babcock and other centrifuge tests for fat are adaptable for labora- 
tory use and purposes. Many physicians are fortunate enough to be able 
to rely upon the services of a friendly apothecary for ordinary analysis. 

To approximately determine the percentage of fat present in the milk 
under investigation, a small calibre test tube graduated from 1 to 100 is 
filled to the 100 mark with milk pumped from the breast, an indefinite 
quantity of ether is added thereto, and the contents are thoroughly shaken. 
After the lapse of half a day, on standing, the liquid separates into two 
layers, ether and fat, and milk minus fat; then, for example, if the point 
of demarcation between the two layers is at 97, we have 3 per cent of 
fat represented in the specimen examined. We now decant the ether and 
fat solution and precipitate the casein contained in the skim milk by the 
addition of acetic acid or rennet; the curd formed is then collected on a 
filter (the weight of the filter being known), and the salts, etc., are washed 
out with water; filter and curd are dried in an oven and weighed together. 
Deduct the weight of the filter from the total weight and the weight of the 
curd remains; thus, e. g., if in a test tube graduated in grammes the weight 
of the curd was found to be 2.0 gm., the percentage of proteid is two, 
approximately. An inexpensive Swiss milk tester in the shape of a flat 
disc can now be obtained, which enables one to tell rich from poor milk 
at a glance. Holt has devised an inexpensive milk tester. 

Summary 

Overfeeding, excessive fats or proteids, may cause dyspeptic symptoms 
in the nursing infant. Proteids and fat in mother's milk may be increased 
or diminished in many cases by diet and exercise. A deterioration of the 
breast milk occurring early or toward the end of lactation is accompanied 
by insufficient gain or loss of weight in the child unless the condition of 
the milk can be improved or an addition made to the child's diet. The 
proteids are high during the colostrum period, and may provoke dyspeptic 
symptoms in the premature or full term infant. 

The dietetic management of infants is not solely a question of ac- 
curate percentages of fat, casein, and sugar; the composition of breast milk 



HOW TO NURSE 111 

varies within certain limits all the time, in the healthiest individuals; it varies 
from day to day and varies within the day. Those who attempt to regulate 
the physiological processes occurring in the animal economy by methods 
brimful of mathematical accuracy, viewed solely from the standpoint 
of chemistry, are as much at fault as those who make no attempt to 
study and understand the subject. The chemical behavior of food stuffs 
in the laboratory is entirely different from the chemical behavior in the 
animal economy. Conclusions drawn from such comparisons as practi- 
cally applicable to the necessities and workings of the human economy are 
frequently grossly erroneous. In our attempts to aid and imitate nature, 
common sense will establish limitations and keep us away from gross scien- 
tific errors. 



HOW TO NURSE 

The new-born child may be put to the breast after the mother has had 
a refreshing sleep. In the mean time or in case the milk is somewhat 
delayed, it may receive warm and sweetened fennel tea. Should the milk 
be delayed beyond the second or third day, artificial feeding must be done 
at regular intervals. Almost all infants can be trained to nurse and sleep 
regularly. Mothers and nurses who fail to appreciate this fact, or lack the 
necessary firmness and common sense, will suffer much wear and tear during 
the nursing period. For the first two months ten feedings a day are the 
average, including two night nursings; and it should be the aim of the 
mother or nurse to accustom the child to abstinence and sleep for four to 
six hours at night. As the child grows older, the intervals between nursings 
increase, and one night nursing will suffice. 

After the child is six to eight weeks old, it should be taken out of doors 
in all but stormy weather for from two to six hours each day. The sleeping 
room should not be heated above 65° to 68° F. Children kept indoors in 
overheated apartments become dyspeptic in a short time. Medication in 
such cases is absurd — fresh air to breathe is Nature's tonic and digestant. 

Wet Nursing. — If maternal feeding is out of the question, a good wet 
nurse is to be preferred to artificial feeding. It is the writer's experience 
that children artificially fed, all other factors being equal, succumb more 
readily to severe infectious disease than do breast fed children. At the 
same time it must be emphasized that in private practice infants can be 
raised on the bottle without much difficult}'. The moral question involved 
in depriving an infant of a poor mother of its natural nourishment is usually 
not taken into serious consideration, but, inasmuch as a healthy woman 
with full breasts can readily nourish two infants until they are several 
months under wa}^, such an arrangement might well be suggested by a 
well meaning physician. 

In selecting a wet nurse, the physician will investigate carefully as to 
marked anaemia, syphilis, tuberculosis, gonorrhoea, the condition of the 
breasts, nipples, lymph nodes, etc.; and endeavor to secure for the nurse 
the proper diet and sufficient rest to insure if possible an adequate supply 
of good milk. A wet nurse need not be rejected if her child is four or six 
weeks older than the one to be nursed. 



112 PAEDIATRICS 

Weaning. — Deterioration in human milk is marked by a reduction in 
the proteids and total solids. This deterioration takes place normally 
during the later months of lactation, and is accompanied by a loss of 
weight, or a gain below the normal standard, unless supplementary feed- 
ing is established. Deterioration may be the forerunner of the cessation 
of lactation, or well directed treatment may improve the condition of the 
milk. 

Weaning should be done gradually and if possible in cold weather, with 
no regard to the period of dentition. Any sudden change in food is apt 
to be followed by indigestion. Sudden weaning may be required in severe 
acute illness of the mother, but if this is of short duration, it is often wise 
to keep up the flow of milk by means of the breast pump. 

In weaning, the artificial food must be of low strength at first, with a 
gradual increase in the strength of the milk food. The mother is made 
more comfortable by a binder holding up the breasts. The management 
of inflamed breasts and sore nipples is discussed elsewhere. 

Mixed feeding is a combination of breast and bottle feeding, and in many 
cases is superior to artificial feeding alone. 

1. The breast milk may be good, but lacking in quantity. 2. It may 
flow well, but be poor in fat. As regards point 1, we can make the intervals 
between the nursings longer and feed by bottle once, twice, or three times. 
As regards point 2, we can endeavor to increase the richness of the breast 
by a special diet for the mother and feed by the bottle several times a day, 
and thus continue lactation for a long time. Mixed feeding is often necessary 
in retarded convalescence after parturition. 

No Drugs for Nursing Infants. — The medicinal mismanagement of dys- 
pepsia, or indigestion, in nursing infants is one of the greatest wrongs that 
a medical adviser can inflict upon the innocent and helpless. Indigestion 
in nursing infants is managed by diot, abstinence, fresh air, and rectal 
enemata, and not by drugs. The following case from the writer's experience 
will serve as an illustration for these remarks: 

A breast fed infant seven days old had a dyspeptic diarrhoea thl-ee days 
after birth. Instead of cutting off the breast milk for a short time and 
feeding on farinaceous water, in order to give the gastroenteric tract a chance 
to readjust itself, the infant was at once drugged according to the prevailing 
fashion, and calomel, lactopeptine, bismuth, and salol were given in rota- 
tion. As there was no improvement, resorcin was ordered in quarter grain 
doses every four hours, and after the sixth dose of this drug the child became 
cyanotic, pulseless, clammy, and cold, and the urine which had been voided 
before collapse set in was smoky in color. Resorcin poisoning was at once 
suspected, and the subsequent management was as follows: The child was 
given a hot bath, 110° F., every two hours and kept warm by hot water 
packs, the bowels were flushed with a warm saline solution every three 
hours, and warm sweetened tea was given by a spoon frequently. The 
child recovered completely in the course of a few days and again took the 
breast at regular intervals and remained well. 



FACTS ABOUT MILK 113 



FACTS ABOUT MILK 

As cow's milk is the basis of artificial infant feeding, its properties 
and the various methods of its handling and its modification should be 
thoroughly understood by the practitioner. For that reason some extra 
space in this volume is devoted to the important subject of milk and milk 
diluents. 

Guaranteed, or certified, milk is pure, clean milk for the nursery as fur- 
nished by dairymen under the following safeguards: (1) The veterinary 
care of the herd and its protection against tuberculosis, sepsis of the udder, 
and other infectious diseases of the cow herself. (2) The medical care of 
the attendants in regard to their health, the hygiene of their homes, and 
the practical quarantine of the farm. The careful sterilization of the milkers' 
clothing and the cleanliness of their hands and arms during the process of 
milking. (3) The care of the cows, the absence of manure in the barns, 
the practical exclusion of faecal matters from the milk, and precautions 
against the entrance of dust. (4) The extraordinary precautions placed 
around the milk in the milk house and in the processes of transportation 
and delivery. 

Standard of Cleanliness 

It has seemed wise to establish a standard of cleanliness, or a bacterial 
standard, to which dealers must conform. The standard prescribed by 
the commission of the Medical Society of the County of New York, and of 
the medical commission of the Walker Gordon Milk Laboratory, and of 
similar commissions in other cities is that the acidity must not be higher 
than 3 per cent, that the milk must not contain more than 30,000 germs, 
or bacteria, of any kind per cubic centimetre, and that the butter (fat) 
must reach 3.5 per cent. 

Out of twenty samples examined on a winter day, November 19th, the 
smallest number of germs found was 90,000, and the highest 2,280,000, 
while on June 29th, with the thermometer at 90°, out of twenty sam- 
ples examined, the smallest number found was 240,000, and the highest 
516,000,000 per cubic centimetre. The prevalence of bacteria, to a great 
extent, arises from the dirt of the milk. "There are seven conditions on 
which the amount of bacteria depends — the cleanliness of the barn, condi- 
tion of the cow, condition of the milker, condition of the utensils, the cooling 
process, the transportation, and the cleaning of the milk bottles before 
they are returned." 

Aeration is not a success to-day as used by the ordinary farmer. In 
good hands it might work all right, but in many cases, as at present used, 
it results in an increase of germs. The three things which are absolutely 
necessary to secure milk comparatively free from germs are strict cleanliness, 
rapid and sufficient cooling, and thorough icing of the milk until it reaches 
the consumers. In the transportation of milk ordinary freight cars should 
not be used, and the ends of the cars should be kept closed, thus preventing 
the heated air from passing through the car and breeding the germs. The 
railroads could be asked to cooperate and furnish refrigerating cars in which 
the milk could be kept constantly on ice, and after being unloaded it 
9 



114 



PAEDIATRICS 



should be re-iced before reaching the dealers. Milk not coming up to this 
standard and cheap milk purchased in grocery stores in large cities are 
absolutely unfit for infant use, and raw milk should not be fed to infants 
unless it is guaranteed at the above described standard of cleanliness. 

Modified Milk ; Adapted Milk. — These terms are used in connection with 
cow's milk which has been modified or adapted by dilution to the needs 
of the infant. Milk may be modified in the household or may be pur- 
chased already modified from the various milk laboratories long since 
established in all large cities. The laboratory modifications are naturally 
higher in price than household modifications. 

Sterilized and Pasteurized Milk. — During hot weather the infant's 
food should be Pasteurized — heated to 167° F. — or sterilized — heated to 

212° F. The bottles of food may be set in 
a kettle of water with a thermometer. 
Heat rapidly to 167° F. and keep the water 
at this temperature for twenty minutes; 
then cool the food rapidly and keep it cool. 

Combined Pasteurizers and sterilizers 
can now be bought with full directions 
for using. Pasteurizing or sterilizing does • 
not increase the digestibility of the food, 
but prevents the growth of germs that 
spoil the food and cause sickness. 

Rationale of Milk Sterilization 

A few words as to the rationale of milk 
sterilization. All of our food, liquid or 
solid, is perishable, and we associate with 
this process of organic decay the terms fer- 
mentation and putrefaction as represent- 
ing those processes in nature by which 
organic substances are split up into their 
elementary constituents, such change being 
usually accompanied by the formation of 
poisonous by-products — ptomaines and 
toxalbumins. In order to hinder a rapid decomposition of our food, we 
make use of methods of preservation, and employ for that purpose in the 
laboratory, as well as in the household, the high and low temperature re- 
spectively known as the freezing and boiling point of water. Now, one of 
the most important, and at the same time one of the most unstable, articles 
of food which enter the household of the rich and poor is cow's milk; and 
as we know at the present time that spoilt milk is the chief factor in the 
causation of summer diarrhoea, we have naturally come to the conclusion 
that the ordinary methods of preserving milk in the household are faulty, 
especially as regards the manipulation of milk intended for infants' use, and 
the suggestions of the German chemist, Soxhlet (whose method of steriliz- 
ing milk in the household is well known in all civilized countries), have been 
most enthusiastically accepted and mark a distinct advance in the rational 




Fig. 47. — Arnold Stehilizek and 
Pasteurizer. 



STERILIZED MILK 115 

prophylaxis of acute gastrointestinal disease. Since the introduction of 
Soxhlet's method to the American profession by the writer, in 1887, 
numerous milk sterilizers have been launched upon the public. The 
different forms of apparatus now obtainable in this country are all con- 
structed on correct scientific principles, and no special designation need be 
made in favor of one or the other. The Arnold sterilizers can be used both 
for Pasteurizing and sterilizing. 

One point must be borne in mind, however : there is no apparatus on the 
market which will make innocuous such milk as already contains the chem- 
ical products of decomposition — the ptomaines. The milk which we subject 
to the sterilizing process should be pure and fresh, otherwise we shall fail 
in our object. Infant mortality in New York city during the hot weather 
has markedly decreased since the introduction of the sterilizing process, 
and depots for the sale of sterilized milk have been established where the 
poor can obtain such milk for about one cent a feeding. 

Sterilizing at a low temperature does not destroy pathogenic germs in 
milk. The question of the transmissibility of the bovine tubercle bacillus 
to human beings is, according to Koch's experiments, sub judice. The 
assumption that the sterilizing process is responsible for the condition 
known as scurvy is erroneous. The Arctic explorer, Dr. Nansen, personally 
told the author that during his three years' trip not one case of scurvy 
developed among his men, and he attributed their immunity to the thor- 
ough sterilization of all perishable food. 

In household sterilization the milk food is steamed in a set of bottles, 
each containing sufficient food for a single feeding, i. e., enough for twenty- 
four hours. The rubber stoppers usually furnished with the steamer are 
to be used only when the milk is to be preserved more than a day or two 
(on a voyage, for instance). Ordinarily a firm pledget of non-absorbent 
cotton is twisted into the neck of the bottle before the heat is applied. 
The bottles are so constructed that they can readily be cleaned; and in 
feeding, the cotton is removed and an ordinary black rubber nipple is 
adjusted. 

In a recent elaborate report issued by the Wisconsin Agricultural College, 
steaming for twenty minutes at 140° F. is recommended as a safe procedure 
for preserving infants' food from day to day. But it must be borne in mind 
that milk food steamed at a temperature below the boiling point of water 
(.212°) will not keep sweet unless rapidly cooled and kept on ice. 

In traveling with infants and young children the ordinary milk obtain- 
able in transit must not be used. An adequate supply of sterilized milk 
food should be carried along. This can be prepared in the household or 
secured from a milk laboratory such as those now established in all large 
cities, or condensed milk or evaporated cream can be carried along and 
diluted with boiled water (1 to 12). 

Pancreatized Milk (Peptonized Milk) 

This is predigested milk prepared with the aid of a "peptonizing 
preparation " which is sold in glass tubes, with full directions for its use. 
In ordinary cases of acute and chronic milk indigestion the writer seldom 



116 PEDIATRICS 

makes use of pancreatized milk. Its use is indicated occasionally for a 
week or two in cases of acute febrile illness, when the stomach is so rebel- 
lious as to reject almost everything put into it, and it is serviceable for 
rectal alimentation whenever it is indicated. Peptonized milk has a bitter 
taste, and children are not fond of it, and it is never indicated as a regular 
food for healthy children. 

Directions for Peptonizing Milk. — Cold Process: 

Pancreatin, gr. v ] , , . , 

c, , , . / * > make 1 pmt. 

Sod. bicarb., gr. xv ) 

Mix the sodium bicarbonate and pancreatin in a cup of cold water. 
Add a pint of cold milk and then shake well and place on ice. 

Hot Process. — Prepare as above directed, but place in a dish of 
water at a temperature of 115°, and keep there for ten minutes. Then 
place on ice. 

Buttermilk. — As nourishment in subacute and chronic diarrhoeal dis- 
ease of infants buttermilk has been recommended by Dutch physicians. 
Some very satisfactory results following its use in older children and con- 
valescent adults have been observed. 

Condensed Milk and Evaporated Cream. — Milk kept in grocery stores 
is unfit for infants' use. When parents are unable to buy pure certified 
milk or are not intelligent enough or willing to handle it properly, fresh 
condensed milk may be fed. It must be diluted with boiled water or barley 
water or oatmeal water in the following proportions: 1 to 12 for the first 
month; 1 to 10 for the third month; 1 to 8 for the sixth month. 

If fresh condensed milk is used, sugar and cream must be added. Canned 
condensed milk is sufficiently sweet and does not require additional sugar. 
Condensed milk sufficiently diluted to bring down the percentage of casein 
to the breast milk standard will require the addition of cream or fat. Evap- 
orated cream in cans may be used for this purpose. Each feeding should 
be separately prepared. Feeding on condensed milk is not expensive and 
is simple as regards its preparation, but the results are not so satisfactory 
as with fresh and pure cow's milk. 

Asses' and Goat's Milk for Infant Food. — Feeding with asses' milk has 
given good results, and is frequently employed in France. Children take 
about one quart of milk a day. Asses' milk comes nearer to human milk 
than any other, but contains a low percentage of fat (one half of 1 per cent), 
and is not adapted for more than the first two months of infancy. Goat's 
milk contains a high percentage of fat. A goat furnishes from two to three 
quarts of milk daily. The milk has a peculiar animal taste unless the goat 
is stall fed. 

DILUENTS OF COW'S MILK 

Boiled Water; Farinaceous Water; Whey. — When raw cow's milk is 
to be fed, the author prefers giving boiled water as a diluent up to three, 
months. When sterilized or Pasteurized cow's milk is to be fed, the writer's 
experience is in accord with the teachings of A. Jacobi, who says: 

"The barley and oatmeal are the two substances I mostly employ, as 
their chemical constituents are nearly alike, with the exception of a large 



MILK DILUENTS 



117 



portion of fat in oatmeal, which is not found in barley. Barley water or 
thinned and sweetened oatmeal may be given to the child even at the breast. 
The indications for the use of one or other lie in the condition of the infant. 
Where there is a decided tendency to constipation, I prefer oatmeal; where 
there is no such tendency, as usual, or perhaps even a tendency of the bowels 
to be loose, I employ barley." 

If whole cereals are used instead of flour, two to four tablespoonfuls 
to a quart must be taken (with some salt), and cooked for one to two hours. 
An equal part of top milk is added to such a decoction and some cane 
sugar. (See article on Home Modification of Cow's Milk.) The mixture, 
when fed, should have a temperature of 80° to 90° F. Whey, deprived of 
its fat, has been suggested as a diluent of cow's milk. 

Dextrinized Gruels. — In exceptional and selected cases more satisfac- 
tory results are obtained if the gruel which is used to dilute or modify the 
cow's milk is dextrinized by means of malt diastase or cereo. 

Whey. — In case of inability to digest the casein of cow's milk, or an 
idiosyncrasy toward milk, the milk can be curdled with rennet or pepsin, 
and the curd removed. 

[ 1 per cent of fat. 
Whey contains -\ 1 per cent of lactalbumin. 
( 4 per cent of sugar. 

In feeding with whey, sugar and cream must be added to make up for 
the deficiency of both in the whey. 

PRESCRIPTION BLANK FOR MILK FOOD 



Per Cent. 



Remarks. 



Fat 

Milk sugar . . . . 
Albuminoids . . . 
Mineral matter. 
Total solids. . . . 
Water 



100 00 



Number of 
feedings 

Amount at 
each feeding. 



Infant's age 

Infant's weight 

Alkalinity % 

Heat at °F 



Ordered for . 



Date, 



Signature, 



118 



PEDIATRICS 



MILK LABORATORIES AND PRESCRIPTION WRITING FOR MILK FOOD 

Through the efforts of Dr. T. Rotch, of Boston, and the Walker-Gordon 
Company, milk laboratories have been established in our large cities in 
connection with model dairies. They furnish pure, clean milk and cream 
of full strength or modified. Milk food is delivered in 
bulk or in bottles containing a single feeding, according to 
the physician's order or prescription. The price for a 
day's rations of modified milk varies from 30 to 80 cents. 
Clean milk is delivered for 15 cents a quart. This plan has 
advanced the knowledge of infant feeding, has made it pos- 
sible for parents to obtain clean milk for their children, 
and is a great convenience in cases in which home modifi- 
cation of cow's milk cannot properly be carried out. 



Babcock Milk Tester 

Several methods of rapidly determining the amount of 
fat contained in milk with the aid of chemical reagents have 
been devised. One of the most accurate is the Babcock 
milk test. The little machine constructed to apply this 
test, of which several patterns are made, is in use in almost 
all well conducted milk receiving stations. It requires 
about a tablespoonful of milk for a sample, and the exact 
percentage of fat in it can be determined by this test in 
ten or fifteen minutes. The result is obtained by the 



/ 



\ 





Fig. 48. — Lactom- 
eter. 



Fig. 49. — Cream Testing Outfit. 



COW'S MILK FOR INFANT FEEDING 119 

action of centrifugal force combined with some chemical effects. The 
original cost of the machine is from $3 to $15, according to size and pat- 
tern, and a few cents' worth of materials are used at each operation. Its 
manipulation is easily learned, and it can be successfully operated by any 
careful person by following the directions which come with the apparatus. 

COW'S MILK FOR INFANT FEEDING 

Our principal aim is to take the composition of mother's milk as a 
standard, and to adjust cow's milk in accordance with this standard, cow's 
milk being the most available substitute for mother's milk which we have. 



Fat. 


Sugar. 


Proteids. 


Human milk 

Cow's milk 


4.00 
4.00 


7.00 
4.00 


1.50 
4 00 







Modification of cow's milk is accomplished by reducing the proportion 
of proteids by dilution ; by increasing the quantity of fat originally sufficient, 
but made insufficient in amount b}^ the necessary dilution; by increasing 
the sugar and salt made insufficient in amount by the necessary dilution. 

The manipulations necessary to modify or adapt cow's milk for infants 
can be carried out in the household or in milk laboratories. The intro- 
duction of percentage feeding has placed infant dietetics on a scientific 
basis and has given us milk laboratories, but success in infant feeding is 
not a matter of accurate percentages — as the general practitioner has 
erroneously inferred. Milk food ordered by prescription according to the 
percentage method and supplied by the laboratory has given very excellent 
results, but we may obtain the same gratifying results by home modifica- 
tions, by simple dilutions, in which the principle of percentage feeding is 
carried out in a simple way. 

For various reasons modifications of cow's milk, whether done in the 
household or in the laboratory, will not give uniform good results in difficult 
feeding cases, no matter how accurate we are in our manipulation of per- 
centages. The chemistry of digestion is very complex, and the alimentary 
canal is not a test tube. The behavior of food in an infected intestine 
or feeble organism is often difficult to understand, and thus our best efforts 
will have their limitations. Success in feeding will not come to us with 
mathematical certainty. Minute differences in the composition of the 
proteids of cow's milk as compared with human milk have a theoretical 
but no practical interest. Suggestions for modifying cow's milk which 
take into consideration the minute differences in chemical composition 
are thrown to the winds. We cannot convert cow's milk into mother's 
milk, no matter how scientific we are. We are obliged to use cow's milk 
as Nature furnishes \t,a.nd. without proper hygienic management neither home 
nor laboratory modification of cow's milk will fit the baby with a capricious 
digestion. With proper hygienic management, however, clean cow's milk, 
properly diluted or modified, will fit the vast majority of infants. 

In the home modification of cow's milk, the greatest simplicity is desir- 



120 



PAEDIATRICS 



able for all concerned. Simple dilution of top milk with water or farinaceous 
water will answer in the vast majority of cases, if the deficiency of sugar 
and salt is made up by adding these substances to the diluted top milk. 

The following simple method of home modification has been practised 
by the writer for the past twenty years: If a quart bottle of average good 
milk stands four hours, the upper half of the milk will contain about twice 
as much fat as the milk before standing. This pint of so called top milk 
is decanted or dipped out by means of the Chapin dipper and forms the 
basis of bottle food for home modification. By diluting this pint of top 
milk in various proportions, viz.: 1-1, 1-2, 1-3, 1-4, 1-5, we obtain a food 
of various strengths as regards fat and proteids. The deficiency of salt and 
sugar is readily made up by the addition of these substances, and a food 
can thus be prepared which will vary in composition according to the 
requirements of the child to be fed. The cost of a daily feeding with the 
best milk obtainable is about twenty cents a day. 

When clean milk can be had, the milk may be given raw. In hot 
weather and with the average milk supply the food must be sterilized. As 
an additional precaution the top milk may be filtered through a layer of 
cotton in a funnel. 



SCHEDULE OF HOME MODIFICATION OF COW's MILK 



No. 1 (1-4). No. 2 (1-3). I No. 3 (1-2). No. 4 (1-1). 



Cane sugar 
Table salt.. 
Diluent . . . . 
Top milk.. 



2 ounces 
35 grains 
26 ounces 

6 ounces 



1 J ounces 

30 grains 

24 ounces 

8 ounces 



1 J ounces 
25 grains 
20 ounces 
10 ounces 



1 ounce 
20 grains 
15 ounces 
15 ounces 



The diluent may be boiled water, oatmeal or barley water, or whey. 



No. 1. — For young infants (one month) and difficult feeding cases. 
Feed 1 to 2 oz. every two hours (twice at night). 

No. 2. — Adapted for young infants with good digestion or for infants 
two to three months old. Feed 2 to 3 oz. every two hours (twice at night). 

No. 3. — Adapted for infants of from four to eight months. Feed 4 to 6 
oz. every two and a half to three hours, eight feedings in twenty-four hours 
(once at night). 

After the eighth month give six bottles and two feedings of cornstarch 
pap with egg, or mutton or beef broth with rice or sago, tapioca, or pea soup. 

No. 4. — Rich milk adapted for children over one year old. Give five 
bottles, 6 to 8 oz. each, and two additional feedings as above mentioned. 

Pour the mixture into small nursing bottles, each to contain one feeding, 
and cork with a pledget of clean cotton and sterilize in warm weather. 
Sterilized milk keeps without ice. Keep raw and Pasteurized milk food 
on ice. Before feeding, heat to the body temperature by placing the bottle 
in hot water. Then remove the cotton and feed by means of a rubber 
nipple. 

This method of modifying cow's milk does away with the addition of 
separated cream and is a distinct advantage over the so called cream mix- 



COW'S MILK FOR INFANT FEEDING 



121 



ture, because separated cream, having a high market value, is not invari- 
ably fresh, has not a uniform composition, and is very prone to spoil 
and give rise to dyspeptic diarrhoeas and symptoms of milk poisoning in 
general. 

Cow's milk modified in the household according to this simple method 
will agree with the vast majority of infants. In a difficult feeding case 
it is best to stop feeding milk for a few days and begin again with a low 
strength modified milk and gradually work up. When we encounter a 
positive idiosyncrasy for cow's milk we may be compelled to make use 
of some other foods. An idiosyncrasy for cow's milk in proper dilution 
should not be suspected until after the children have had proper hygienic 
management to help them digest their milk. 

Infants and children who are kept indoors in cool and cold weather, 
and breathe the air of overheated and stuffy living apartments, will not 





Chapin dipper. 



Fig. 50. 



Fig. 51. — Seibert's Aluminum Milk- 
Filter, WITH Cotton Disk. 



digest well, no matter what they feed on. It should be made a practice to 
send infants out of doors from the time that they are six weeks old. The 
insane fear of breathing cool fresh air is almost as pronounced to-day as 
it was in times before the advent of the germ theory of disease, and is re- 
sponsible for most of the indigestion among children. A move in the right 
direction as regards the hygienic management of infants and children has 
been started in Boston by some of the wealthy families in the Back Bay 
district, who put their babies to sleep in a box on the flat roof or on a 
balcony or window sill, summer and winter. The method is begun when 
the baby is two months old, and may be continued as long as the custom 
of having a daily nap is kept up. 

The baby is wrapped like an Indian papoose and strapped to the box 
or basket in such a way as to give freedom to the feet and arms and yet 
make it impossible for the child to crawl out. The crib is shielded from the 
wind and direct sun rays by an awning overhead. If the outdoor treatment 
is carried out, drugs and digestive ferments and the peptonizing process 
are hardlv ever indicated. 



122 PAEDIATRICS 

To sum up, I would say that there are no universal rules for feeding 
cow's milk. What we must aim at is to individualize in each and every 
case, and not attempt to adapt one form of feeding to all cases and under 
all conditions. In a difficult feeding case cow's milk should be discontinued 
for a short time and cereal decoction and white of egg, etc., substituted. 
In resuming cow's milk we begin with a low strength and gradually work 
up to full strength milk and avoid overfeeding. Digestion of cow's milk 
is best stimulated by carrying children out of doors, not by drugging. 
Digestive ferments and peptonized milk are rarely indicated. 

Idiosyncrasy for cow's milk is managed by selecting some substitute 
food, if possible the breast of a wet nurse. In some cases whey with cream 
and cereal decoction will fit the baby. The whey proteids differ as to 
digestibility from the casein. 

Cow's milk should be sterilized (steamed) in warm weather. The pres- 
ervation of cow's milk by means of a harmless chemical is a desideratum; 
because the heating process slightly alters the digestibility of cow's milk. 
Behring has suggested the use of formaldehyde for preparing a permanent 
milk (1 to 10,000). Infants will usually thrive on properly modified cow's 
milk up to seven months. After the seventh or eighth month they are apt 
to become rhachitic unless they receive beef or mutton broth, with cereals 
and egg, in addition to cow's milk. With proper hygienic management 
to stimulate the motor function of the gastroenteric tract, we may let the 
secretions take care of themselves. 

How to Feed. — Select round, wide mouthed, graduated nursing bottle, 
and use black rubber nipples. Hold the bottle upside down and see that 
the hole in the nipple is large enough to allow the food to drop slowly, not 
run in a stream. Heat the food by placing the bottle in warm water for 
a few minutes, or heat the contents of the bottle in a dipper over a fire 
and return to the same bottle. Shake the bottle before feeding. Never 
warm any food that may be left in the bottle. Throw it away. Never 
give anything but cool water that has been boiled, between meals. As 
a rule, children do not get enough water. 

Care of Nursing Bottles. — After feeding, rinse the bottle with cold water, 
and then wash with hot solution of borax (one teaspoonful to a quart) 
and a bottle brush. When the bottle is not in use, keep it full of water and 
the nipple lying in water in which a little borax has been dissolved. Before 
using the bottles, scald them with boiling water. 

Raw milk should be fed only during the cold months. As soon as warm 
weather sets in the bottle food (milk food) must be sterilized or Pasteurized. 

Strength of Milk Food. — In ordering milk for an infant, not only its age 
but its weight must be taken into account. There are some cases where 
the strength of the milk food may be increased rapidly. Usually it is 
best to begin with low strength milk food and gradually increase as the 
child gets older and heavier. The critical time in infant feeding is the first 
two months, and the difficult feeding cases are those in which infants have 
made a bad start. 

It must be distinctly understood that there are no set formulae for the 
various ages and weights of infants. The digestive capacity for food and 
food components — fats, proteids, and cereals — is different in various in- 



COW'S MILK FOR INFANT FEEDING 



123 



dividuals and at various periods. It is lessened in hot weather and illness, 
and increased in cold weather. A steady increase in weight and the appear- 
ance of two gamboge yellow stools a day are the best indications of good 
feeding. The strength of the food may be modified once a month to suit 
the condition of the child. 



TABLE FOR THE FEEDING OP THE HEALTHY INFANT DURING THE FIRST YEAR 





Number of 






Percentages 


OF 


Ages. 


feedings within 


Quantity for each feeding. 
















24 hours. 




Fat. 


Sugar of milk. 


Proteids. 


let week 


10 


i-1 oz. 15-'30cc 


2. 


5. 


0.50 


2d week 


10 


1 -l^oz. 30- 4.5 cc 


2.25 


5-6 


0.50-0.75 


3d-4th week 


10-9 


U-2 oz. 45- 60 cc 


2.50 


6. 


0.75-0.90 


4th-6th week 


9-8 


2 -2i oz. 60- 75 cc 


3. 


6-6.50 


0.90-1. 


6th-8th week 


9-8 


2J-3 oz. 75- 90 cc 


3. 


6.50 


1.00-1.25 


3d month 


8 


3-4 oz. 90-120 cc 


3. 


7. 


1.25-1.50 


4th month 


8-7 


4-5 oz. 120-150 cc 


3.50 


7. 


1.50-1.75 


5th month 


8-7 


5-6 oz. 150-180 cc 


3.50 


7. 


1.75 


6th-7th month 


7 


6-7 oz. 180-210 cc 


4. 


7. 


1.75-2. 


8th-9th month 


7-6 


7-8 oz. 210-240 cc 


4. 


7-6 


2.00-2.50 


10th-12th month 


7-6 


8 oz. 240 cc 


4. 


5. 


2.50-3.50 



Indications for Varying the Percentage of Fat, Sugar, and Proteids for 
Healthy Infants. — The exact indications for varying the percentage of fat, 
sugar, and proteids in cow's milk cannot be given in the present state of 
our knowledge. An excess of sugar usually gives colic, thin, green, acid 
stools, causing eructation of gas from the stomach and some regurgitation 
and frequent passages of nearly normal appearance; in some cases round 
masses of fat are passed. Too little fat shows constipation and dry hard 
stools (also observed in children who get sufficient fat). The writer has rarely 
ordered milk food with more than 4 per cent of fat. 

An indication of excess in proteids, or imperfect digestion of proteids, 
are the curds in the stool and colic, sometimes with constipation or diarrhoea 
or vomiting and regurgitation. Imperfect digestion of proteids or fat from 
lack of fresh air, from keeping children in overheated, close rooms, causes 
nearly the same symptoms as indigestion from other causes. It is therefore 
unwise to modify the milk so as to meet every temporary symptom of dis- 
comfort in the infant, but we should try the fresh air plan first, then reduce 
amount of feeding and finally modify the milk or food. If the symptoms 
persist, it will be necessary to cleanse the gastroenteric tract by means 
of a dose of oil, rhubarb and soda, or calomel, and give farinaceous water 
and white of egg for a few days and then return to a bottle food of less 
strength, which is more apt to be digested. For infants who are unable to 
assimilate the milk dilutions here recommended it is best to procure a wet 
nurse without much loss of time. The management of difficult feeding 
cases is discussed elsewhere. Premature infants, if deprived of breast 
milk, are fed on low strength food by means of a medicine dropper. They 
take from a drachm to an ounce about every two hours, and should be 
fed slowly. 



124 PEDIATRICS 

DIET FOR CHILDREN AFTER WEANING OR DURING THE SECOND YEAR 
OF BOTTLE FEEDING AND AFTER THREE YEARS 

Milk. — Full or of half strength — sterilized or Pasteurized in summer. 

Cereals. — Oatmeal, farina, hominy, etc., well cooked. Cracked oats, 
cream of wheat, Pettijohn, rice, force, with salt, sugar, or cinnamon, with 
and without fresh cream or top milk. 

Toast, milk toast, zwieback, crackers, sweet crackers, bread and butter. 

Meat broth, soups with cereals, with egg, with toast; eggs, scrambled, 
custard. After eighteen months give minced meat. Water boiled and 
cooled. 

Diet for Children from Two to Three Years Old. — Add mutton chops, 
rare beef, soft boiled eggs, baked apples, stewed prunes, and orange juice, 

Diet after Three Years. — 

Soups. — Plain soups and broths of nearly any kind. 

Eggs. — In any form, soft boiled, omelette, scrambled, poached, or beaten 
in milk. 

Meats. — Beef, beefsteak, lamb, mutton, lamb chops, chicken, and turkey, 
broiled, roasted, or boiled. 

Fish. — Any kind, boiled or broiled. 

Vegetables. — Peas, beans, spinach, lettuce, potatoes, tomatoes, as- 
paragus tips, stewed celery. 

Cereals. — Oatmeal, rice, hominy, wheat, barley, corn meal, wheat and 
graham bread, toast, zwieback, oatmeal, soda and water crackers, maca- 
roni, etc. 

Fruits. — Nearly all stewed or sweetened, peaches, pears, plums, oranges. 

Dessert. — Light puddings, custards, jellies, ice cream, honey, chocolate. 
(Most of the jams in the shops are artificial or adulterated.) 

Young children should be fed five times a day; they usually take from 
two to three pints of fluid food; some children will be hungry at all times 
and others have a capricious appetite. The nibbling of food between meals 
destroys the appetite. No food will agree unless the children exercise. 
The craving of children for sweets should not be entirely ignored. School 
children should have a short vacation at reasonable intervals or as soon as 
they show marked fatigue. Children's digestion suffers but little from 
romping after a meal. 

DISORDERS OF THE DIGESTIVE TRACT 

GENERAL REMARKS 

This group of ailments is intimately connected with the various problems 
in infant feeding and oral and general hygiene. A clear understanding of 
such a relationship is a valuable accomplishment in the family practitioner. 
To look upon acute inflammatory diarrhoea as due to bacterial invasion 
and largely preventable marks a great advance in pediatric practice as com- 
pared with our former views on the aetiology of diarrhoeal disorders, which 
centred in worms, teething, and "catching cold." To make a physiological 
process like dentition responsible for innumerable ills and sins is certainly 



DISORDERS OF THE DIGESTIVE TRACT 125 

convenient and about as rational as to assume that the growth of hair or 
nails bears a causal relation to parasitic and other skin disease. 

Admitting that teething in some infants may cause pain, it is best to 
ignore dentition as an etiological factor in sickness, and thus attempt to 
eradicate a popular superstition which has at all times worked untold harm. 
Let it be understood by mothers and nurses that the second summer diar- 
rhoeas have a causal relation to a change in feeding or to faulty feeding, not 
to dentition, and that the treatment is dietetic and hygienic, not medicinal. 
Cases of primary inanition from too little food (such as scanty breast milk) 
are not apt to occur in bottle fed children. On the other hand, indigestion 
and dyspepsia or fermentative diarrhoea are not rare in breast fed infants 
from overfeeding or poor breast milk. In bottle fed children, however, 
and particularly in hot weather, diarrhoeal disease is an every day occurrence. 

Spoilt food, overfeeding, faulty hygiene, and weak digestive powers 
are provocative of indigestion, and lead to temporary or prolonged malnu- 
trition. The so called difficult feeding cases frequently develop into in- 
flammatory diarrhoeas of severe type or lead to the various forms of mal- 
nutrition and intestinal toxaemia, such as atrophy, rhachitis, and scurvy. 
From the mild to the severe forms we have one chain of pathological con- 
ditions. Thus the timely treatment of a mild form of diarrhoea may 
prevent a dangerous cholera infantum, etc. 

After indigestion has persisted for a time, atony and dilation of the 
stomach result. In the more active inflammatory diarrhoeas structural 
changes in the intestinal mucosa are found, and frequently grave complica- 
tions follow such structural changes. 

Renal Complications of Acute Enteric Disorders. — Degenerative changes 
in the kidneys occur in many cases of prolonged intestinal indigestion and 
inflammatory diarrhoeas, due to the action of bacteria and toxines. In 
such cases albumin and renal elements are found in the urine. When found 
in cases of infantile atrophy they are of grave prognostic import. 

Regarding the nomenclature of gastrointestinal disorders, it may be 
remarked that in the present state of our knowledge a purely anatomical 
or purely microbial nomenclature of diarrhoeal diseases is impossible. A 
simple diarrhoea may be of nervous or psychic origin or may be due to over- 
feeding and food fermentation, during which substances are formed which 
have a laxative action or a toxic action (milk poisoning), or diarrhoea may 
be symptomatic, as in the course of infectious and organic disease. The 
catarrhal or inflammatory diarrhoeas are all due to microbial invasion of the 
intestine itself. Acute gastroenteritis and enterocolitis in children are 
evidence of such local infection. The mild forms may terminate in severe 
forms. The Bacillus dysenterice described by Shiga in 1898 seems to bear 
some etiological relation to the diarrhoeas of infancy, and has been found in 
the mild inflammatory forms as w^ell as in the severe forms in breast fed 
and bottle fed children. The results of the treatment with antidysenteric 
serum have so far been disappointing. All inflammatory diarrhoeas are 
communicable. The hand that attends to the toilet of a sick child should 
not feed the well children. 



126 PEDIATRICS 



AILMENTS OF THE MOUTH IN CHILDREN 

Slobbering of Infants. — This manifestation, which is aptly enough de- 
scribed by the name accorded it, is not of infrequent occurrence in early 
infancy and during the period of active dentition. Though frequently 
ascribed to local irritation, difficult dentition, and uncleanliness, it is not 
necessarily so caused, and is often met with in idiots, epileptics, and the 
morally and physically degenerate. 

Bleeding of the Gums. — Independently of the acute inflammatory affec- 
tions of the gums, bleeding is observed in scurvy. (See Scurvy.) When the 
bleeding does not respond to simple methods, prolonged pressure over the 
bleeding spot with a pledget of cotton saturated with alum solution, or a 
10 per cent antipyrine solution or adrenalin solution, or the actual cautery 
may be applied. 

Stomatitis Catarrhalis. — This form of inflammation is usually of a mild 
type, runs an acute course terminating in about a week, and is not associated 
with pronounced constitutional symptoms. It is generally observed during 
infancy and is caused by the introduction of irritating and unclean sub- 
stances into the mouth (e. g., dirty fingers, unclean nipples). It may be con- 
comitant with or secondary to the exanthemata and to gastrointestinal 
affections. The symptoms are mild. There is some rise in temperature; 
the mouth at first is red, dry, and hot. Thirst, pain, and irritability are 
present. Later the mouth becomes moist and there is increased saliva- 
tion. The changes in the mucous membrane consist simply of local 
hypera^mia, increased epithelial proliferation, and subsequent desquama- 
tion with little or no tendency to ulceration. 

The TREATMENT of this affection consists in keeping the mouth clean 
with a 2 per cent boric acid solution or a mild solution of borax in water 
and glycerin. Should constipation exist, a mild laxatixe may be given. 

Stomatitis Follicularis (Aphthous, or Vesicular, Form). — This is of 
severer type and longer duration than the simple catarrhal form. The local 
tissue changes are more marked and the constitutional disturbance is more 
pronounced. Causative agents are any of the severer constitutional dis- 
eases, a deteriorated state of health, malnutrition, and unhygienic conditions 
and surroundings. The change observed in the mucous membrane con- 
sists in the appearance of vesicles which ulcerate and have swollen, well 
defined, grayish yellow denuded surfaces. The affection is in many instances 
so painful that the child refuses nourishment. 

Treatment. — A pale rose colored solution of potassium permanganate 
or boric acid, 6 parts; salicylic acid, 1 part; water, 500 parts, or alum 
water (a teaspoonful to the pint), should be used as a mouth wash and gargle. 
The mouth may be swabbed frequently with cotton pledgets moistened 
with one of the solutions. Other agents which may be employed are: 

Tannic acid, 3j ) or> j ^ ■ j. c 

p, . tt • ^ 30 drops to a pmt of water. 

Or Labarraque's solution in water, 1 part to 20. 

Croupous or Membranous Stomatitis. — Abrasions, wounds, and inflamma- 
tory lesions in the mouth or nasopharynx are frequently found to be covered 



AILMENTS OF THE MOUTH IN CHILDREN 127 

with a yellow pseudomembrane, which may be diphtheritic or non-diphthe- 
ritic. This occurs frequently as a complication of the eruptive fevers and 
whooping cough and following operations in the mouth or on the tonsils. 
From the mouth it may spread to the nasopharynx and larynx. When it 
invades the latter, it may manifest itself as membranous croup, and in this 
respect the significance of membranous stomatitis is underestimated in 
general practice. A culture from the mouth will reveal the presence or 
absence of diphtheria bacilli. When they are present, 1,000 to 2,000 units 
of antitoxine should be injected in the usual way in order to prevent 
further systemic infection. The local treatment is the same as for ordinary 
forms of stomatitis. 

Thrush, or Muguet, frequently termed Sprue (Mycetogenetic Stomatitis), 
is a form of stomatitis caused by the organism termed Oidium Albicans. 
On the tongue or buccal mucosa numerous small white pellicles appear, 
frequently coalescing and invading the epithelial and mucous surfaces. 
The disease is of very frequent occurrence in young infants and is probably 
caused by local uncleanliness. Soiled nipples, dirty stoppers and bottles, 
and dirty clothes are agents which carry the infection to the mouth. Poorly 
nourished and delicate children are the frequent subjects of thrush. Its 
distinguishing features are the small white flakes resembling coagulated 
milk. On attempting to forcibly swab these particles away, small bleeding 
points appear at their site. Microscopical examination of the deposit 
shows the organism. 

Treatment. — The mouth should be gently wiped out with a borax 
or bicarbonate of sodium solution before and after each feeding, and every- 
thing that is carried into the mouth should be clean. 

Tongue tie is due to a short frenum, and in consequence protrusion of 
the tongue is interfered with, sucking is embarrassed, and the condition 
if not remedied, will eventually interfere with distinct articulation. To 
remedy the deformity, the frenum is " nitched " with small scissors in a 
direction downward and backward to avoid the ranine artery, which lies 
in the fold of the frenum, running up along the base of the tongue. 

Tongue Swallowing. — Asphyxia from swallowing the tongue, owing to 
its riding over and shutting off the opening of the glottis, is occasionally 
observed. The tongue is drawn back and down over the glottis by the 
muscles of deglutition, and this is due to congenitally long or large tongue 
or lax frenum. This condition calls for immediate relief. The tip of the 
tongue may be caught up by the finger, forceps, or suture and drawn for- 
ward whenever the danger of asphyxia threatens. 

Strawberry Tongue. — This name is given to a bright red appearance of 
the anterior part of the tongue with the filiform papillae glistening through 
the mucous lingual surface. This condition is typical of scarlet fever in 
the early stage of the disease. 

Geographic Tongue. — This is occasioned by local desquamation of the 
lingual epithelium in patches. The bases of the patches are red and of 
irregular maplike shape, hence the term geographic. This condition is of 
parasitic origin and may last for months. Special treatment is unnecessary. 

Dental Ulceration (Riga's Disease). — The presence of carious teeth in 
the mouth and prolonged friction of the tongue or frenum against the teeth 



128 PEDIATRICS 

are causes. As a rule, touching the base of the ulcer a few times with a 5 
per cent nitrate of silver solution suffices to cure. Decayed teeth should 
be extracted or filled. 

Sublingtial Ulcer. — This is frequently met with in children suffering from 
whooping cough; the ulcer presents itself where the frenum is in contact 
with the incisor teeth. 

The TREATMENT resolvcs itself into cleansing the ulcer and occasionally 
touching it with lunar caustic to encourage healthy granulation and repair. 

Sublingual Granulation Tumor. — This may be removed by scissors or 
scraped away with a spoon or cauterized with lunar caustic. The mouth 
must be kept clean by means of mild antiseptic solutions. 

Herpes of the Lips. — Herpes blisters develop on the lips in the course of 
febrile disease. Camphor ice acts admirably as a soothing application. 

Perlesche starts at the angle of the mouth as a small fissure and spreads 
as an ulcer covered with a grayish exudate. 

The TREATMENT is cleauliness, cauterization with nitrate of silver, and 
protecting with camphor ice. 

Cracks and Fissures of the Lips. — This condition requires stretching of 
the lip and the application of nitrate of silver and camphor ice. 

Eczema of the lips yields to mild protecting ointments. 

Sordes. — A brown coating of the lips in febrile disease. The treatment 
consists in washing and applying camphor ice. 

Protruding Tongue of Cretins. — (See Cretins.) All other conditions of 
the mouth and tongue are discussed in the chapter on Diseases of the 
Mouth. 

MUMPS; PAROTITIS 

An infection of the parotid or other salivary glands, characterized by 
a swelling of the gland or glands and mild constitutional symptoms. In- 
fants are rarely afflicted; most cases occur in children between three and 
fourteen. 

The epidemic parotitis is contagious and therefore of microbial origin. 
The contagium has not been isolated. The portal of entrance is probably 
the buccal cavity; therefore hygiene of the mouth is the best preventive. 
Three weeks after the termination of a case the danger of infecting others 
is probably over. 

Symptoms and Differential Diagnosis. — Malaise, fever (101° to 103°^ 
headache, vomiting, pain in the angle of the jaw, localized swelling on one 
or both sides, a disagreeable pressure sensation, and dryness. Chewing and 
speaking are painful and difficult. The swelling disappears after from eight 
to ten days. 

Mumps may be confounded with acute swelling of the central lymph 
nod9s. In mumps the lobe of the ear is near the centre of the enlargement. 
The enlarged lymph nodes are behind the ear and behind the jaw, never 
upon the face. The swollen neck, as observed in some cases of tonsillitis, 
diphtheria, or scarlatina or measles with throat complications, should not 
been mistaken for mumps. On the other hand, inflammation and suppura- 
tion of the parotid gland may complicate an infectious disease, as in typhoid 
fever and various forms of sepsis and by extension in otitis media. 



INDIGESTION AND DIARRHCEAL DISORDERS 129 

Treatment. — Unless the symptoms are severe, the patient may be up 
and about in fresh air. The diet should be restricted and the bowels opened 
by from three to five grains each of calomel and jalap. The nasopharyngeal 
toilet with salt water should be employed, and antiseptic gargles and 
mouth washes are indicated. If the symptoms are severe, the patient 
is put to bed on fever diet. Ichthyol vaseline (3 per cent) or camphorated 
oil may be gently rubbed over the painful swelling, and an ice bag or hot 
water bag may be applied. A sympathetic swelling of the other glan- 
dular organs (orchitis, mastitis, ophoritis) and of the joints usually subsides 
with the parotitis. Otitis media and deafness, and meningitis by ex- 
tension, are rare sequela:>. In suppuration of the gland incision and drain- 
age are indicated. Prognosis is favorable. 

INDIGESTION AND DIARRHCEAL DISORDERS 

HABITUAL CONSTIPATION AND DIFFICULTIES OF DEFyECATION 

IN INFANTS 

Straining at stool and constipation are found in infants principally under 
the following conditions: Weak peristalsis from lack of muscular develop- 
ment in the rectum and difficulty of overcoming resistance at the rectal 
valve, as in congenital and acquired rickets; low percentage of fat and of 
total solids in the food; fissures at the anus, giving pain in d efa3 cation : 
chronic intestinal indigestion with constipation and "putty stools "; opium 
preparations given secretly to quiet the child. 

A weak peristalsis will ultimately be overcome by the process of develop- 
ment, and forcible dilatation of the sphincter is readily performed. Fis- 
sures require dilatation of the sphincter and cauterization with a 2 per cent 
nitrate of silver solution. 

Aside from the selection of the proper diet in rhachitic infants we may 
aid nature in overcoming constipation by increasing the fat and solids 
in the food; administering fruit juices (prune juice) and Vichy water or 
sulphate of sodium (10 grs.) ; administering soap suds enemata or soap 
suppositories; gentle massage of the abdomen and vibratory massage; 
keeping children out of doors all day. (See also general article on 
Constipation.) 

COLIC AND VOMITING 

Colic. — The distention due to the formation of gases in the intestines 
is probably the cause of pain. Bottle fed children are very apt to suffer 
from this condition, which is a strong indication for reducing the strength 
of the food. An attack of colic is treated by giving a warm soap suds enema, 
a warm bath of 95° F., and warm fennel or mint tea to drink. Opium is 
rarely necessary. The relief which follows these measures will enable the 
physician to exclude intestinal obstruction or appendicitis. It should be 
borne in mind that small umbilical hernias are sometimes responsible for 
recurring attacks of colic, also renal gravel. 

Simple Vomiting. — Frequent vomiting is a very annoying symptom, 
and food is rejected very soon after it is taken into the stomach. Should 
10 



130 PEDIATRICS 

fresh air treatment and a reduction of the food strength not give satisfactory 
results the following prescription may be offered: 

I^ Tinct. iodini, gtt. x; 

Aq. menth. pip., 3 vj ; 

Syrupi sacchari, 3ij. 

M. et signa: A teaspoonful every hour or two. 

Habitual vomiting may often be overcome if the children are fed by 
gavage. (See General Therapeutics.) Persistent vomiting and rapid ema- 
ciation in the new-born are suggestive of pyloric stenosis. 

Recurrent Vomiting; Cyclic Vomiting. — Obstinate and repeated vom- 
iting is the most striking symptom, coupled with thirst, a bad odor from 
the mouth, emaciation, and exhaustion. The attack may last from one 
half to fourteen days and is looked upon as a toxic neurosis. A differ- 
ential diagnosis must be made between periodic vomiting, vomiting in acute 
infectious disease, in acute indigestion, in intestinal obstruction, and in 
meningitis. 

Recurrent vomiting is autotoxic in origin and characterized by repeated 
attacks of nausea, persistent vomiting, and great prostration. The great 
majority of cases occur during infancy and childhood. Heredity is the 
most important predisposing factor. A general neurotic inheritance is 
common. Nearly all of these patients are constipated, and this condition 
is doubtless an important setiological factor. Overeating is a very potent 
factor. Warning symptoms are flushings of the cheek, coryza, general 
restlessness, nervous irritability, sleeplessness, sallowness of the complexion, 
dark rings under the eyes, general malaise, constipation, and loss of appetite. 
Vomiting follows the prodromes in from six to forty-eight hours. After an 
attack the stomach, as a rule, resumes its functions. Thirst is a striking 
symptom. Emaciation is extreme in long continued cases. Gastric pain is 
not present in these attacks in childrep. Nervousness is very marked. The 
urine is very concentrated. The prognosis in relation to recovery is good. 

Treatment of Recurrent Vomiting. — The sources of reflex irrita- 
tion should be sought for and removed, if possible. 

Diet. — Reduction of food strength. 

Fresh Air. — Six to eight hours out of doors daily. 

Enteroclysis. — Daily. (See General Therapeutics.) 

Tincture of iodine internally in drop doses every hour in sugar water 
during the attack. 

Stomach washing in severe cases. In the interval apply hydrotherapeutic 
measures and abdominal massage. 

ACUTE INDIGESTION 

Mild Form Acute Dyspepsia, Gastricismus. — This is due to dietetic 
imprudence, overfeeding at the breast or by the bottle, and unsuitable, 
irritating, or decomposing food. 

Symptoms. — Eructation, nausea, vomiting, coated tongue, loss of 
appetite, thirst, usually no fever. There may be constipation or diarrhoea 
and evidence of dull pain. 



ACUTE INDIGESTION IN INFANTS 131 

Principles of Treatment, — Relieve the gastroenteric tract; restrict 
food (no food for six to twelve hours) ; quench thirst by giving water or 
tea or toast water; give cool sponge baths in warm weather; carry the 
child into the open air. 

If vomiting and diarrhoea coexist, the stomach and intestine will soon 
be relieved. If not, advise a dose of castor oil or calomel (six half grain 
doses with sugar should be given every half hour) and plenty of boiled cool 
water or toast water to quench thirst. If the tongue remains coated twenty- 
four hours after the bowels have moved, the following prescription will aid 
digestion and may be given to children over one year old: 

I^ Acid, hydrochloric, dil., gtt. x; 

Ess. pepsin 5j. 

A teaspoonful after feeding, 

A dyspeptic attack requires no other medication. 

Milk should not be given for a day or two; farinaceous or mucilaginous 
drinks may be given instead. 

Substitute diet in Indigestion and Diarrhcea when milk is contra- 
indicated : 

Young Infants. Older Children. 

Oatmeal water. Cornstarch pap. 

Barley water. Burnt flour soup. 

Rice water. Farina. 

Gum arable water. Beef broth. 

Peppermint tea. Mutton broth. 

Toast water. Bouillon and egg. 
White of egg and water. 

As soon as the dyspeptic symptoms have ceased, we return to breast 
feeding (if not otherwise contraindicated) or to the proper bottle food, 
with a caution not to overfeed. 



ACUTE CATARRHAL GASTRITIS IN INFANTS 

Severe Type. — Infants at the breast or on the bottle frequently be- 
come acutely ill with high fever (105° to 106°), rapid pulse and rapid 
breathing, great unrest, twitching or convulsions, and vomiting with and 
without diarrhoea. These symptoms are sometimes quite alarming, and 
are due to acute milk poisoning with gastric irritation. They very much 
resemble the sudden onset of other acute infectious diseases. In the 
absence of throat symptoms and meningeal symptoms, the true nature of the 
onset will be recognized by the experienced practitioner. 

Management. — Stop feeding milk; give farinaceous drinks only; give 
a warm bath (95° F.) ; give a warm soap suds enema. In the way of medi- 
cation, four to six half grain doses of calomel may be given, one every hour. 
The temperature usually drops to the normal in twelve to twenty-four 
hours, after which it will be safe to give the breast at proper intervals. 

Bottle fed babies should receive, for a week, diluted cow's milk of less 
strength than before the attack, according to the directions given in the 



132 PAEDIATRICS 

chapter on the Home Modification of Milk. In warm weather this milk 
should be sterilized. If the tongue remains coated, children over a year old 
may take two drops of dilute hydrochloric acid in essence of pepsin 
twice daily; and children of all ages must be kept in the open air as long 
as possible, or may be taken on a boat to derive the benefit afforded 
by the sea air. 

DIFFICULT FEEDING CASES IN BOTTLE FED INFANTS 
(PROLONGED INDIGESTION) 

Here we have to deal with children who have not been properly fed 
for weeks and months, or perhaps not since birth. All kinds of food have 
been given in succession, with or without drugs in addition. 

Symptoms. — Regurgitation, vomiting, colic; diarrha3a or constipation; 
incessant crying, no sleep, loss of weight; green stools with curds and some 
mucus. The children appear to be hungry. They become rhachitic or 
show evidence of scurvy, or they have slight general oedema, but are not 
yet in a condition of marasmus. The urine is free and there is no hypostatic 
congestion of the lungs. 

Treatment. — Medication is hardly ever indicated in cases of this nature. 
If the infant is not over three to four months old, the question of a wet 
nurse must be decided at once. If artificial feeding is to be continued, it 
will be best in some cases to wash the stomach and bowels once or twice 
with boiled water. (See chapter on General Therapeutics.) After thus 
cleansing the gastroenteric tract, feed from the list given under the heading 
of substitute diet. Give no milk for the time being. Have the child 
taken out of doors from four to six hours or into the country or on water 
trips. Also give a warm bath or a cool sponge bath in warm weather. 

Next in importance to the selection of proper food comes the hygienic 
management of the infant. A child should be constantly in the open air 
and out of the sun. It is also good practice to cleanse the mouth with a 
boric acid solution before nursing or feeding, particularly in the summer, 
for even germ-free breast milk or sterile cow's milk may become contami- 
nated by the bacteria residing in the oral cavity and thus infect the entire 
gastroenteric tract. 

Irrigation of the stomach and bowels may have to be repeated daily 
or every other day for a week or ten days. In extreme cases, when children 
get no rest day or night, we may allow them one dose of paregoric at night, 
ten to thirty drops, or a teaspoonful of the following mixture, also at night: 

I^ Chloral hydrate, | _ _ ^ ^. 

Potass, bromid., j ' ' 

Aq. cinnam., 5j- 

Ft. solut. 

It is not wise to resume milk feeding as soon as improvement is notice- 
able; it is better to wait a week or more. Then feel your way with low 
strength raw top milk (1 to 4) or sterilized top milk (1 to 4) in summer, 
or with white of egg and top milk, and discontinue irrigation as soon as 
possible. 



CHRONIC INDIGESTION IN OLDER CHILDREN 133 



TOP MILK AND WHITE OP EGG 

I^ Water, one pint and a half; 

Top milk, one half pint; 

Sugar, 13 drachms; 

White of egg, one. 

Sometimes whey with or without cream is tolerated best. Under certain 
circumstances diluted condensed milk (1 to 12) with evaporated cream 
added will be tolerated and digested, or some proprietary food may be tried. 

In cold weather and in private practice, when it is possible to see a 
child at least every other day, it usually takes, on an average, two weeks of 
well directed effort to put the child on a proper feeding basis. No universal 
rule can be formulated which will insure success in the management of 
this class of cases. The physician must learn to individualize and feed in 
each particular case on its merits. If, after a reasonable trial with milk 
in various dilutions (during which time the children are to be out of doors 
all day, even in cold weather), a milk idiosyncrasy is evident, we must give 
up cow's milk feeding and nourish with food from the following : Meat broths 
and cereal decoctions with and without yolk of egg; gum arable solution; 
white of egg in water; burnt flour gruel; cornstarch pap with egg. 

CHRONIC INDIGESTION IN OLDER CHILDREN 

The class of cases to be considered under this heading includes those of 
[children who are off the bottle from two years up, also school children with 
chronic dyspepsia. They are pale, sallow, yellowish, and flabby, and have 
I no ambition or appetite. Some are constipated, others have liquid, offensive 
[stools, or gray, pasty stools. The tongue is coated, the breath is offensive, 
land they are subject to follicular stomatitis, have bad teeth, and are ex- 
'tremely nervous and irritable, particularly if they have a nervous mother. 
[They grind their teeth in their sleep. A neurone suppression of urine is 
[Occasionally observed and attacks of constipation lasting a week may set 
[in with stupor, slow, irregular pulse, simulating intestinal obstruction or 
[even meningitis, and many other phenomena due to intestinal toxaemia 
I are observed. The temperature during such an attack is seldom above 
102°, often normal or subnormal; the urine is brown from indican. 

Associated with chronic indigestion we frequently find enuresis, reflex 
I cough (adenoids), night and day terrors, vulvovaginal discharges, etc. 

In all such cases a careful clinical examination is called for in order to get 
at the underlying cause of the trouble and be able to manage the case intelli- 
gently. This may involve a regional, blood, urine, and stool examination. 
.Etiology. — The underlying cause may be syphilis, tuberculosis, malaria, 
malignant disease, rhachitis, scurvy, diabetes, renal disease, hepatic dis- 
ease, cardiac disease, or pulmonary disease, central nervous disease, atony 
of the stomach, constipation, faulty diet (indulgence in candy, nuts, soft 
drinks), constant swallowing of pus from chronic nasopharyngeal catarrh, 
adenoids, etc. 

Neurotic parents are often responsible for the indisposition of the 
children by reason of keeping them indoors or in overheated rooms for fear 



134 PEDIATRICS 

of their "catching cold." The extreme of mismanagement was observed 
by the writer in a neurotic family as follows: The mother, with the aid of 
an accommodating medical talent, had a padded box stall constructed, five 
feet square and four feet high, closed on four sides. This was placed in 
the middle of the nursery and the little "two year old " was kept in close 
confinement during the day in this box in custody of a trained nurse for 
seven months of the year, in order to prevent colds and cough, to which 
the child was subject. On careful examination this tendency to "catch 
cold " was found to be due to adenoid vegetations in the nasopharynx. 

When the mother of a suffering child is not open to reason and the father 
is lucid, the physician should enlist the services of a nurse with diplomacy 
to manage the child properly, keeping the mother at bay. When both 
parents are dense, the case is almost hopeless, and the medical attendant 
will have to worry along or shift the responsibility to other shoulders. 

Treatment. — The treatment of cases of chronic dyspepsia in older chil- 
dren involves, therefore, in addition to the dietetic management, a study 
of the underlying cause and special treatment directed against the same. 
Furthermore, we must seek to establish regular habits in the child and 
reduce the neurotic tendencies by a daily sponge bath. 

The sleeping room should be cool and the living room not above 70° F. 
The child should be in the open air all day in fair weather and only come 
in for its meals. A change of climate is important in severe cases. The 
bowels should be made to move once a day, and massage of the abdomen 
or whole body should be performed daily. Older children should be sent 
to a gymnasium, and occasionally kept from school for a week or two when 
they appear fatigued or overworked. Gavage and stomach washing have 
their unpleasant features in older children with teeth, and will not as a rule 
be necessary. To aid digestion and overcome intestinal putrefaction, give 

I^ Acid, hydrochloric, dil., 5j ; 

Ess. pepsin., 5ij ,* 

Tinct. quassiae, 5j- 

M. S : A teaspoonful three times a day. 

Ichthyol in emulsion, in one or two drop doses twice a day, has given 
good results in some cases. A plain diet adapted to the age and condition 
of the child should be ordered. Cabbage, beans, raw fruit, spoilt milk 
or cream, ice cream, sweets, soda water, etc., are forbidden. Maltine and 
cascara may be given to keep the bowels open, also enemata. The under- 
lying cause must be treated. Give iron, phosphorus, arsenic for anaemia, 
quinine for chronic malarial disease (two to five grains every other day in 
a teaspoonful of compound elixir of taraxacum) . 

ACUTE FORMS OF DIARRHCEA 

Dyspeptic Diarrhcea; Simple Diarrhoea 

The term summer diarrhoea may be applied to this form, but should 
not be used in connection with gastroenteritis, which is always catarrhal 
or inflammatory. The danger of a simple diarrhoea in summer lies in the 
fact that it paves the way for severe inflammatory diarrhoeas, and its timely 



SEVERE ACUTE FORMS OF DIARRHOEA 135 

treatment prevents dangerous disease. Simple diarrhoeas are usually of 
nervous or dyspeptic origin. 

Prophylaxis. — Diarrhoeas can generally be prevented if the bottle food is 
sterilized before the warm weather sets in. 

Treatment. — First remove the cause. Undigested food must be removed 
by administering a laxative, such as castor oil (one to two teaspoonf uls) . 
In addition, the colon may be flushed. Calomel may be administered in 
half grain doses every hour until six are taken. The milk food, breast or 
bottle, must be stopped at once, and slimy gruel of barley or oatmeal, gum 
arable water, white of egg in water or toast water given instead. The 
infant should be kept quiet and have good air. In summer a change of air 
is often a necessity from seashore to mountains or from mountains to sea- 
shore. In and around New York City, use may advantageously be made 
of the Staten Island ferry and Coney Island and Long Branch boats for 
the sea air. Refreshing sponge baths should be given. Ten to twenty drops 
of whiskey may be given in water several times a day as a stimulant in 
selected cases. 

Drugs to check the diarrhoea are usually not necessary. Should the 
stools remain liquid in spite of the above outlined management, the follow- 
ing may be administered: 

I^ Bismuth, subcarb., 5ss. ; 

Aq. cinnam., 5ij ,* 

Tinct. opii, gtt. ij. 

M. Sig.: A teaspoonf ul every three hours. 

The medicine is to be stopped as soon as the diarrhoea is checked. 

In returning to milk feeding, we proceed cautiously. The breast is 
offered at longer intervals, and the bottle milk should be given in greater 
dilution and less frequently than before the attack. In warm weather the 
bottle food should be sterilized. 

SEVERE ACUTE FORMS OF DIARRHCEA 

Acute Gastroenteritis (Cholera Infantum). — In order to make it clear 
[to all concerned that there is a vast prognostic difference between a dys- 
peptic and an inflammatory diarrhoea in infants, the term "summer diar- 
rhoea," which is used indiscriminately for diarrhoeas occurring in warm 
.weather, should be dropped or used only in connection with simple diar- 
jrhoea. The term "cholera infantum " is so universally employed in our 
[country that it may be wise to retain it for all cases of acute gastroenteritis 
iin infants, with the distinct understanding that we have to deal with two 
clinical varieties of this disease — the ordinary form and the choleraic form 
(grave form) , which differ only in severity, as do the ordinary and severe 
; forms of scarlatina and other infections. Cholera infantum is an acute 
gastroenteric inflammation not due to exposure to cold or to teething, but 
due to bacterial infection of the gastroenteric tract and to the absorption of 
toxic products from fermentative and putrefactive changes in the stomach and 
intestines. It is in fact a case of milk poisoning from bacteria. In large 
cities cholera infantum becomes epidemic in June, July, and August, and, 



136 PAEDIATRICS 

according to the investigation of A. Seibert, of New York, temperatures 
above 60° F. are provocative of epidemic diarrhoeas. This coincides with 
our knowledge of the turning point of milk, which is about 60° F. The 
summer heat, therefore, not alone produces a constitutional depression, hut 
is at the same time a causative factor of the fermentative change in infant's 
food, milk. The bacteriology of the intestine in these cases has been care- 
fully investigated by William Booker, of Baltimore, and others in our 
country, and by Baginsky and Escherich in Germany, but they are unable 
as yet to formulate a bacterial nomenclature of inflammatory diarrhoea. 

Symptoms and Prognosis. — Cases may develop gradually and in the 
wake of dyspeptic diarrhoea (subacute form), or suddenly after symptoms 
of indigestion of short duration. Fever, thirst, retching, and vomiting 
are the initial symptoms. Diarrhoea soon sets in. The stools may be 
of any color, with flatus of foul odor and accompanied by pain. The 
diarrhoea may be very profuse, and after a day or two the stools show mucus. 
There is great prostration with restlessness, and the heart's action is rapid. 
If the conditions are unfavorable and no improvement sets in, death may 
ensue in stupor or convulsions with cerebral oedema (hydrencephaloid). 
A fall of temperature and of the pulse rate, a lessened frequency of stools, 
and cessation of vomiting are favorable symptoms. Children over two 
years old usually recover; infants are in great danger from this disease. 
Much depends upon early judicious management. In other cases the 
stomach irritation ceases, but the stools remain diarrhoeal with mucus 
and streaks of blood (ileocolitis). 

Prophylaxis. — Bottle fed infants should receive only sterilized food in 
hot weather. When a dyspeptic diarrhoea develops, the milk food should 
be stopped for a day or two and other food given. The child should be 
taken to the seashore or mountains or on day excursions. Children should 
receive sponge baths several times a day in the summer and cooled boiled 
water to drink. Overfeeding is bad. Weaning should not be attempted 
in hot weather. With such precautions cholera infantum is not apt to 
develop. 

Soxhlet's method of home sterilization of milk was introduced to the 
American profession in 1887, and its general adoption and the distribution 
of sterilized milk to the poor of New York City during the summer has 
resulted in a marked decrease of inflammatory diarrhoeas, which in ante- 
sterilizing days killed thousands of infants during the summer. It is now 
nothing unusual for colleagues practising among the middle and better 
classes to go through a summer without handling a single case of cholera 
infantum. 

Treatment of Cholera Infantum (ordinary type). At an early stage 
give no food for six to twelve hours. Give ice. peppermint tea, or black 
tea, to which may be added five drops of whiskey if a stimulant is needed. 
On the following day select as nourishment one, two, or three articles from 
the following list: Barley gruel, oatmeal gruel, white of egg in water, gum 
arable in water, cold tea, whiskey and water, lime water, bread water, 
mutton broth, cornstarch pap, burnt flour soup. 

If the vomiting persists, the stomach may be washed once or twice on 
that day. 



f 



SEVERE ACUTE FORMS OF DIARRH(EA 137 

The indications are: 1. To quench thirst; 2. To rest the gastrointes- 
tinal tract; 3. Antifermentative medication; 4. Stimulation and preven- 
tion of collapse. 

To meet indications 2 and 3 we employ the following drugs: 

I^ Bismuth, subcarb., 5j ; 

Aquae cinnam., 3ij ; 

Tinct. opii, gtt. ij. 

M. Sig. : A teaspoonful every one to two hours. 

Or, 

I^ Acid, carbolic, pur., gtt. ij ad vj; 

Mucilaginis, 5ij- 

M. Sig.: A teaspoonful every two hours. 

Or, 

I^ Argenti nitratis, gr. ij ; 

Aquae distil.; 5ij. 

M. Sig.: A teaspoonful every two hours. 

Or, 

I^ Resorcin, gr. ij ; 

Aquae cinnamomi, 5ij ; 

Tinct. opii, gtt. ij. 

M. Sig. : A teaspoonful every two hours. 

We avoid the addition of syrup to a mixture, if possible, and omit the 
opium, if the patient apparently has little or no pain. When children are 
very restless, and show by their actions that they suffer pain, we do not 
hesitate to give small doses of opium, one, two, or three drops of the tincture 
in a two ounce mixture. In cases of circulatory failure with pulmonary 
oedema opium is contraindicated. A towel wrung out of cold water and 
secured over the abdomen appears to relieve pain, and a warm mustard 
bath stimulates in impending collapse. 

For obstinate vomiting we frequently give: 

I^ Tinct. iodin., gtt. xv; 

Aquae menthae, 5 j ; 

Syrupi simpl., 3ij. 

M. S. : Fifteen drops every hour. 

In obstinate vomiting stomach washing is indicated. A change of air 
is of the utmost importance. Children taken from a hot tenement to the 
seashore or any cool, shady place improve perceptibly in a short time, 
if not too far collapsed. Large enemata of tepid water, with or without 
the addition of some antiseptic drug (acid, salicyl.), should be tried in ob- 
stinate cases, but in dispensary practice this method cannot well be carried 
out. Stimulation must not be delayed until symptoms of collapse are 
marked. Young children with a high temperature, cold and clammy 
feet and hands, and a pulse too rapid to be counted, are frequently stimu- 
lated in vain. The best stimulations are: Camphor, strychnine, caffeine, 
enteroclysis, and hypodermoclysis. 



138 PEDIATRICS 

Their dosage and manner of employment are given in the chapter on 
General Therapeutics. Ice may be applied to the nape of the neck, and 
atropia sulphate may be given hypodermically in -^-^ to yot grain doses. 

During the period of convalescence, the mucilaginous and farinaceous 
preparations already mentioned must be given until all danger of relapse 
is over, and eventually milk feeding (sterilized and modified cow's milk) 
is resumed. 

When there is a tendency to loose stools during the period of convales- 
cence the following astringent drugs may be ordered. 

I^ Acid, tannic, gr. ij ; 

Pulv. Doveri, gr- i; 

Chocolat., gr. V. 

Or, 

I^ Plumb, acet., gr. ^; 

Pulv. Doveri, gr. J ; 

Sacchari, gr. v. 

M. S. : One powder four times a day. 

I^ Bismuth, subnitrat., 5ij; 

Aquae, 5xiv; 

Ext. kramerise, 5 j ; 

Syrup., 5ij. 

M. S. : A teaspoonful four times a day. 

Tannigen and Tannalhin may prove valuable instead of plain tannin. 
Lozenges of tannate of quinine with chocolate are readily eaten by children 
on account of their pleasant taste. 

The severe form of acute gastroenteritis has a sudden onset with con- 
stant vomiting, high temperature, intense thirst, restlessness, cold surface, 
depressed fontanelles, glassy eyes, and early collapse. In consequence of 
the profuse drain from the stomach and bowels, the patient's body wastes 
rapidly, the eyes grow hollow, the nose becomes sharp, the cheeks fall in, 
and the features look pinched and drawn, while the flesh loses its elasticity, 
the abdomen is flaccid or shrunken, and the urine is scanty. 

Prognosis. — The prognosis in the severe form of cholera infantum is 
unfavorable. If infants survive the first two or three days, they may 
recover. 

Treatment of the Severe Form. — In the first stage food is a source 
of irritation and must be withheld for hours. It is well to wash the stomach 
and give cold water or cold peppermint tea to quench the thirst, also ice. 
The bowels should be irrigated with hot saline solutions to wash away 
putrid material and counteract collapse. The tincture of iodine prescrip- 
tion may be ordered. The surface circulation may be kept up by repeated 
hot packs or baths at 100° F. Black tea and whiskey may be given, and 
hypodermic stimulation employed. 

I^ 01. amygdal., 5jv; 

Camphor., gr. xv. 

M. S.: Five to ten drops subcutaneously every three hours. 



MEMBRANOUS ENTERITIS, OR DYSENTERY 139 

Or, 

I^ Sp. frumenti, 5ij ; 

Fl. ext. digit., gtt. v. 

M. S.: Five to ten drops subcutaneously every four hours. 

When recovery takes place, farinaceous and mucilaginous drinks with 
yolk and white of egg in water may be fed for a week or until it is safe to 
return to diluted sterilized milk. 

ENTEROCOLITIS, OR FOLLICULAR ENTERITIS 

This is an infection of the bowel without marked gastric irritation. 

Symptoms and Prognosis. — Diarrhoea, blood streaked, mucous stools. 
Fever with constitutional depression, as in cholera infantum, and a less 
severe prognosis. 

The TREATMENT is dietetic, medicinal, and local (irrigation of bowel). 
During the acute stage the dietetic management is the same as in acute 
cholera infantum. Bowel irrigation should be employed at once if for no 
other purpose than to bring away putrid material. Irrigation of the bowel 
is possible up to the caecum. Use a flexible tube. Elevate the hips. Irri- 
gate from one to three times a day with warm boiled water or starch water. 

Rectal suppositories to quiet pain: 
^ Ext. opii, 



Ext. belladonna, j ^^' ^^- *' 

Butyr. cacao, gr- v. 

M. S. : Use one to three a day. 

Reduce high temperature by baths and sponging. Medicinal antipyretics 
are not to be resorted to in diarrhoeal disorders. The graduated cool bath 
(reduced from 95° to 80°), continued until the rectal temperature has mark- 
edly fallen, is the proper means in all cases in which the high tempera- 
ture calls for antiphlogistic measures. After the bath the warmth of the 
feet is maintained by hot water bags. 

MEMBRANOUS ENTERITIS, OR DYSENTERY 

A severe and often ulcerative inflammation of the lower bowel. 

Symptoms and Prognosis. — Bloody diarrhoea, with mucus, tenesmus, 
fever. Often fatal in infants. Older children frequently recover. 

Treatment is the same as for enterocolitis as regards diet and stimula- 
tion. In the way of medication, opium, bismuth, and astringent drugs 
are indicated when the dietetic management and bowel flushing alone 
are inadequate. In dysentery irrigation of the lower bowel with boiled 
medicated water is particularly useful. Use salicylic acid, 1 to 1,000, or 
argentic nitrate, 3j to 1 pint. 

The drugs to be given internally are the astringent drugs mentioned 
under cholera infantum. The antidysenteric serum treatment in cases 
of enterocolitis due to the Shiga bacillus has not been followed by note- 
worthy good results up to the present time. The dose of the serum is 
10 cc. injected once or twice a day. 



140 PEDIATRICS 



CHRONIC DIARRHOEA 



Chronic diarrhoea in children is usually dyspeptic or fermentative; 
sometimes neurotic; symptomatic, as in hepatic, cardiac, renal, and other 
disease, or due to a previous catarrhal and ulcerative colitis. 

The Management of the first two varieties has been sufficiently discussed 
under Acute and Chronic Indigestion. The symptomatic diarrhoeas will 
receive brief mention under the various diseases in which they occur. 
Generally speaking, their prognosis depends upon the underlying cause. 
If a child has a chronic diarrhcBa associated with diabetes or some other 
fatal disease, the prognosis is bad; and if it is associated with conditions 
which can be bettered or removed, the prognosis is good. The Prognosis 
depends upon so many factors that it cannot be formulated en masse. 
Chronic diarrhoea is a grave disturbance in weaklings, but an absolutely 
hopeless attitude is not justified except in intestinal tuberculosis and 
other fatal diseases. 

The Management of a chronic symptomatic diarrhoea involves: Change 
of air, irrigation of the bowel, careful dieting, stimulation, and astringent 
medication. 

Specimen Diet. — Burnt flour gruel; slimy soup, with or without egg; 
cornstarch pap; scraped meat; mucilage of gum arable; rice; farina; mashed 
potatoes; sterilized milk and lime water; buttermilk; albumirized food; 
tropon in mint tea; tropon with iron. 

In such cases the peptonized foods have rarely been satisfactory. Good 
buttermilk, recommended by the Dutch physicians, has given marked 
satisfaction in a number of cases. 

Medicinal Treatment. — Bismuth in large doses, 5 to 10 grains four 
times a day, with opium and with fluid extract of krameria. 

Tannic acid, 2 to 5 grains several times a day. 

Acetate of lead with Dover's powder, gr. ^ of each three times a day. 

Tinct. Jerri, chlor., 5 drops three times a day. 

Lozenges of tannate of quinine and chocolate. 

As an aid to digestion the author employs: 

I^ Acid, hydrochloric, dil., | __ -.. 

Tinct. quassias, . ) ' ''■ 

M. S.: Five to ten drops in sugar water after eating. 

Stimulation is occasionally necessary with port wine, sherry wine, or 
blackberry brandy. 

Chronic Diarrhoea from Protracted Ileocolitis. — In protracted or chronic 
ileocolitis the catarrhal or rarely ulcerative changes in the intestine are 
frequently associated with, bronchopneumonia or hypostatic congestion in 
the lungs, with large or fatty liver, and albuminuria (kidney congestion 
and nephritis). All this goes to show that a microbial diarrhoea was the 
starting point, and that the infection first located in the intestine has 
found its way into adjoining organs and tissues. 

Symptoms. — The symptoms are those of intestinal irritation and rest- 
lessness, flatulence, and occasionally colic with malnutrition and malas- 



CHRONIC DIARRHOEA 141 

similation. The children waste to a skeleton, are anaemic, have fissured 
mucous membranes (with sordes) which bleed readily. The skin hangs 
loose and the mouth may be the seat of thrush or stomatitis. There may 
be half a dozen stools a day, and sometimes vomiting is observed. The 
stools are thin, often green, contain mucus, and are offensive. Under the 
microscope the stools are found to contain pus, some blood, food remnants, 
and epithelial debris. The lymph nodes (inguinal and abdominal) are 
generally enlarged, the skin of the abdomen has lost all its fat and is thin, 
and the dilated and atonic intestine (colon) bulges out under the flabby 
parietes. Skin excoriations and ulcerations are present over various parts 
of the body, due to poor surface circulation, the pulse is weak, the extremities 
are cold, respiration is shallow, and the temperature is often subnormal. 
Dropsy of the feet is occasionally seen. The nervous system is blunted 
and convulsions are rare. Toward the end an ordinary or tuberculous 
bronchopneumonia usually sets in. 

Chronic diarrhoea from intestinal ulcer may be due to simple ulceration 
in consequence of necrotic thrombosis of a small area of the intestinal mucosa 
or to syphilis or tuberculosis. Even malignant disease may be the under- 
lying cause. A careful local examination with the finger and speculum 
may reveal an ulcerated condition. Also there should be an examination 
of the stools. When the small bowel is the seat of a lesion, the pain is of 
a colicky character and the faeces give a bile reaction. When the lower 
bowel is affected there are tenesmus, mucus, and pain. 

Treatment. — Accessible ulceration will require local treatment in the 
way of rectal irrigation with nitrate of silver solution (5j to 1 pint). 
Ichthyol and tannin may be given internally, and suppositories per rectum 
to quiet pain (see Enterocolitis). The diet and medication are the same 
as for the other varieties. 

In chronic diarrhoea from mesenteric, intestinal, and peritoneal tuber- 
culosis or malignant disease of the bowel the treatment is symptomatic; 
medication will not cure. But almost every patient should have the benefit 
of the doubt and receive antisyphilitic treatment by inunctions of mer- 
curial ointment, with potassium iodide, internally. In chronic diarrhoea 
from peritoneal tuberculosis laparotomy should be done, and it has saved 
lives. In older children suffering from ulcerative colitis a colonic fistula 
may be established and the bowel may be irrigated from above downward. 

Chronic mucous colitis in which mucous discharges are the prominent 
feature should be treated as a neurotic diarrhoea, and rectal irrigations 
should not be continued for any length of time in such cases. 

Amoebic Diarrhoea. — In this form living amoebae are found in the warm 
liquid stools (see Laboratory Diagnosis.) Their significance is not under- 
stood. The treatment is as for other forms of diarrhoea plus rectal douching 
with quinine bisulphate, gr. xx to 1 pint of water, or with ichthyol in 2 per 
cent watery solution, or irrigation through a colonic fistula in intractable 
cases (see also amoebic Diarrhoea in adults). 



142 



PEDIATRICS 



MALNUTRITION AND INTESTINAL TOXAEMIA (MARASMUS, 
RHACHITIS, SCURVY) 

Infantile atrophy (marasmus) is that form of malnutrition in infants 
and young children in which the child ceases to digest its food and gradually 
dwindles away and dies with all the symptoms of acute starvation. Starva- 
tion is a relative term in such cases, for it is not due to lack of food. The 
stomach may be regularly filled, but the power of extracting nourishment 
from the food is wanting. The infant grows thinner and more feeble daily, 




Fig. 52. — Rachitic Flat Foot in Child of Nine Months. 

and, worn out by purging, pain, and want of sleep, dies. This ailment 
occurs most frequently during the first half year of life. Atrophy of the 
thymus gland is usually found in cases of marasmus. 

The starting point may be an acute indigestion or inflammatory diarrhoea 
from spoilt food milk. If at the time a proper food is selected, the trouble 
is promptly overcome. If not, malnutrition becomes chronic and finally 
the period arrives when no amount of manipulation will save the child. 
Infants at the breast may show malnutrition to a certain degree, but seldom 
get into the atrophic, marantic condition. The symptoms are those of pro- 
gressive severe malnutrition (starvation), wasting, crying, little sleep, 
sunken fontanelles, stools scanty or diarrhoeal, vomiting, anaemia, and 
flabbiness. 

Differential Diagnosis. — Marasmus must not be confounded with 
ordinary starvation, and we must remember that mesenteric or intes- 



MARASMUS AND RICKETS 



143 



blood serum have been tried in 
Treatment with suprarenal and 



tinal tuberculosis or syphilis may be the underlying cause of a wasting 
process. 

Prognosis in a case of advanced atrophy in a young infant is bad, but 
no case should be given up as hopeless when the heart is sound and the 
lungs and kidneys are free. 

Treatment. — Change of air from sea to mountain, or from mountain 
to sea, cleanliness of the mouth, and warm sponge baths. For young infants 
a wet nurse should be obtained. Top milk diluted, 1 to 3, sterilized or 
Pasteurized in summer, raw in cold weather, should be fed, the strength of 
the milk to be increased gradually. The stomach should be washed once 
a day if vomiting is a prominent symptom, particularly in older children. 
Whey and cream may be given, or asses' milk if it can be obtained. If a 
milk idiosyncrasy appears to be established, select from the list of sub- 
stitute foods recommended for such conditions (see Difficult Feeding 
Cases). Subcutaneous injections of 
infantile atrophy with negative results 
thyreoid extract has also been tried and 
found useless. Hypodermic injections 
of salt water (one ounce a day) have 
apparently benefited some patients. 

RICKETS, RHACHITIS 

A peculiar manifestation of malnu- 
trition or impaired nutrition. Rickets, 
like gout, has local and general mani- 
festations most marked in the first two 
years of life. The bones and cartilages 
show characteristic changes . The epiph- 
yses persist, and the medullary canal 
shows an excess of unfinished bone pro- 
duction (osteoid tissue). The stability 
of the skeleton is subnormal. These 
changes take place at the time of the 
best growth of bone (one to two years) . 
Foetal rhachitis is described. In rha- 
chitis the general nutrition is below 

par, and changes occur in various organs. Marked fatty tissue may be 
observed. Some children become emaciated, particularly if suffering from 
severe diarrhcea. The muscles are flabby and soft (pseudo-paralysis). 
Bronchitis, pneumonia, enteritis, enlargement of the liver and spleen, 
spasmus glottidis, eclampsia, and tetany are noticed. The children have 
capricious appetites and walk late or lose the power of walking; the teeth 
come late; the cranial bones are soft (craniotabes). The fontanelles remain 
open. It has been shown that there is no lack of assimilation of lime salt 
in rhachitic children, and it is more likely that in rhachitis we have to deal 
with a diseased condition of the bone-forming cells. 

Rhachitis is associated with a faulty diet and hygiene. It is a common 
disorder in bottle fed children and particularly such as fail to get meat 




Fig. 53. — Comfortable Position for 
Children with Rhachitic Weak 
Back. 



144 



PAEDIATRICS 



broth and farinaceous gruels with their milk after the seventh or eighth month. 
Whereas chronic intestinal indigestion will often end in scurvy, rhachitis 
may develop in children who have shown little or no intestinal catarrh and 
intestinal toxaemia. 

Clinical Forms of Rickets. — Bone Rickets. — Craniotabes (soft cra- 
nium); rosary at the ribs; chicken breast; rhachitic spine; curvatures of 
the spine; bow legs; knock knees; square cranium (caput quadratum, 
with hydrocephalus combined); deformed clavicles; flat foot; pelvic de- 
formity, etc.; enlargement of the epiphyses, etc. 

Muscle Rickets. — In rickets the muscles become flabby and powerless 
(pseudoparalysis) . Children who have walked, fail to walk. 

Fat Rickets. — This term is used when children show only slight changes 
in the bone and are excessively fat. Pot belly is the term in vogue to desig- 
nate the large abdomen of 
rhachitic children. Of ner- 
vous symptoms, we have 
laryngismus, tetany, convul- 
sions, nystagmus, head nod- 
ding, tics, hydrocephalus, 
sweating of the head. 

Generally speaking, rha- 
chitis is accompanied by a 
tendency to catarrh of all 
mucous membranes and a 
feeble resistance to other in- 
tercurrent disease. 

Rheumatic and scorbu- 
tic changes in and near the 
joints or epiphyses may be 
distinguished from rhachitic 
swellings by means of x rays. 
Rhachitic bone gives only a 
faint shadow in the x ray 
print. To discriminate be- 
tween rickets and joint 
manifestations of congenital 
syphilis is difficult, in the 
absence of a syphilitic his- 
tory. Infants are frequently 
rhachitic and syphilitic at 
one and the same time. 

Prophylaxis and Treat- 
ment. — To prevent a child 
from becoming rickety, we 
must carefully attend to its diet, its digestion, and its hygiene. This in- 
volves all that has been said under Infant Feeding, breast, mixed, or 
bottle feeding. At the end of the seventh month meat broth and gruel 
with yolk of egg should be fed twice a day in addition to the five bottles 
of milk food. Children must live outdoors in good weather and sleep in 




Fig. 



54. — Carrying-Frame for Feeble Rhachitic 
Children. 



SCURVY IN CHILDREN 



145 



r 



cool rooms, and they must have a daily movement of the bowels. A similar 
management must be enforced to prevent children who are rickety from 
becoming more so. Children a year old and over may have rice, sago, 
farina, hominy with egg, beef broth, and toast crumbs, and may nibble 
a chop bone. The milk should be 
rich in fat. 

Of drugs, iron, arsenic, phos- 
phorus are lauded and appear in- 
dicated. 

Syr. Jerri iodid., 10 drops three 
times a day. 

Fowler's solution, 1 drop three 
times a day. 

Elix. phosph. (U. S. Ph.), 5 to 
15 drops three times a day. 

Thompson's solution of phos- 
phorus, 10 drops three times a day. 

Such drugs are to be admin- 
istered for two to four weeks 
and then discontinued for a week 
or two. 

The thyreoid therapy, recom- 
mended for rhachitis, has been 
tried by the author in the Babies' 
Ward of the New York Post Grad- 
uate Hospital without showing 
noteworthy results. Malt prepa- 
rations and fruit juice are ser- 
viceable for children one year old 
and over. 

Bow legs and knock knees are 
rectified surgically by osteotomy. 
The results are good. A rhachitic 
thorax and spine may need gym- 
nastics and orthopaedic management (see Orthopsedics). Fractures of long 
bones (green stick fractures) and epiphyseal detachments require splinting. 
Laryngismus stridulus is managed by means of cold sponge baths and 
bromide of sodium internally. In a few instan;ces, and in urgent cases, 
the writer has tubed the larynx for hours and once for a week with very 
satisfactory results in cases of laryngismus. 




Fig. 55. — Rhachitic Defoumity. 



SCURVY IN CHILDREN 1 

Scurvy is an acquired " haemorrhagic diathesis " from intestinal putre- 
faction and toxaemia. This view is the more plausible if we remember that 
in hepatic, renal, and other disease we frequently notice in the later stages 
" haemorrhagic " phenomena which we may attribute to the same causes, 

' Sec collective investigation on Scurvy in America, by the American Piediatric 
Society. 

11 




Fig. 56. — Rhachitis. 
Genu Varum before operation. 



Fig. 57. — Rhachitis. 
Genu Varum after operation. 





\ 



Fig. 58. — Rhachitis. 
Genu Valgum before operation. 



Fig. 59. — Rhachitis. 
Genu Valgum after operation. 



SCURVY IN CHILDREN 



147 



viz., intestinal putrefaction and toxaemia. In adults the lack of fresh 
vegetables in the diet was formerly looked upon as the causative factor in 
scurvy. This view is erroneous. The Arctic explorer, Mr. Nansen, person- 
ally told the wTiter that during his three years' trip in the Fram not one case 
of scurvy developed among his party, and he attributes this remarkable 
immunity to the careful sterilization of all the perishable food taken along. 

Pellagra, Maidismus, the so called Alpine scurvy, is due to the use of 
diseased maize as food. Scurvj^ in children 
follows the prolonged use of improper food. 

Sterilizing, Pasteurizing, or cooking of 
milk is not per se responsible for the scurvy 
condition. Scurvy may develop in infants 
and children fed on breast milk, cow's milk 
(raw, sterilized, or Pasteurized), condensed 
milk, proprietary foods, etc. Out of 379 
cases reported, only 12 had scurvy at the 
breast; all the others were bottle fed. 
Scurvy may be prevented, therefore, by 
selecting for each individual bottle fed child 
the food which it will digest and upon which 
it will thrive and gain. 

Characteristic Symptoms in Scurvy are: 
Anaemia, pain on motion or handling, dis- 
coloration of the gums, subcutaneous and 
free haemorrhages, swellings about the joints, 
spontaneous detachment of the epiphyses 
from the shafts of the bones, etc. Pain is 
clearly a very prominent symptom of the 
disease. Generally it is evident only when 
the child is moved or tries to move itself. 
Sometimes it is so intense that the approach 
of any one to the bedside is sufficient to 
cause the child to scream out through fear of 
being touched. The legs are usually flexed. 

Local swelling (haemorrhages) may in- 
volve the soft tissues or may be subperios- 
teal. Protrusion of one or Ijoth eyes is probably due to orbital haemorrhage. 
The gums are slightly swollen or discolored, spongy and ulcerated, and 
frequently bleed on being touched. A purpuric eruption and petechiae 
are sometimes seen, and occasionally spontaneous haemorrhages from the 
gums, nose, bowels, stomach, and genitourinary ^tract. 

Fractures in infantile scurvy are usually separations of the epiphyses 
merely and are rare. Fever is often present but is not a prominent symptom. 
Anoemia and malnutrition are usually present and the percentage of haemo- 
globin is much reduced. 

Prognosis is favorable if the disease is recognized in good time. 

Treatment. — Change of food, preferably to raw milk in cold weather; 
fruit juice or hydrochloric acid; cleanliness of the mouth; fresh air; treat- 
ment of any underlying cause; bowel washing. 




Fig. 60. — Inpantile Scurvy and 
Marasmus (F. Huber). 



148 



PJ5DIATRICS 




Differential Diagnosis. — It is necessary to make a differential diagnosis 
between scurvy and the following diseases: 

Rheumatic or Gonorrhoeal Arthritis. — The joints, not the bone shafts, are 
involved; fever is high; characteristic scurvy symptoms are absent. 

Rhachitis. — Rhachitic rosary; no 
marked pain; no ecchymosis or pe- 
techial or spongy gums; rhachitis and 
scurvy may coexist. 

Purpura. — No history of improper 
feeding; rapid improvement of scurvy 
under treatment. 

Infantile Paralysis. — Sudden onset 
with fever; difference of electrical re- 
action in the two diseases. 

Syphilis may coexist with scurvy. 
The difference in the history must be 
taken into consideration. 

Stomatitis. — This has none of the 
associated symptoms of scorbutic sore 
mouth. 

WORMS IN CHILDREN 

The alimentary tract in children is 
apt to harbor three kinds of worms : 
Round Worm (Ascaris Lumbri- 
coiDEs) ; Pin or Seat Worms (Oxyuris 
Vermicularis); Tapeworm (T^nia), 

The round worm is brown in color and is from four to eight inches long. 
It usually inhabits the small intestine. 

Symptoms and Diagnosis. — Colicky pain with occasionally a blood 
streaked stool may lead one to suspect worms. A positive diagnosis is based 
upon the passage of the parasite or the recognition of its ova in the stools. 

Treatment. — A dose of maltine with cascara at night and one grain of 
santonin with sugar the following morning, to be repeated five or six times 
for five or six consecutive days. 

The pin worm inhabits the large intestine and rectum, and has been 
found in the appendix (case of Dr. Inslee H. Berry, of New York city). 

Symptoms and Diagnosis. — Pin worms produce intense itching at the 
anus, and may be picked out of the anus in children. 

Treatment. — A strong decoction of garlic in milk is injected with a 
piston syringe or fountain syringe once or twice a day after a cleansing 
enema of soap suds. Camphor ice or cold cream may be applied to the anus 
to overcome the itching and pruritus. 

The Tapeworm. — A tapeworm gives symptoms, but the only certain 
indication of the existence of the worm is the passage of the links or a section 
of the worm. 

Treatment. — One week before administering the tapeworm remedy, 
five drops of oil of turpentine and five drops of compound spirits of ether 
should be given on sugar three times a day. One day before administering 



Fig. 61. — TuiiERcvLOLts Pkkitonitis 
WITH Ascites. 



TUBERCULOUS PERITONITIS IN CHILDREN 



149 



the remedy, a saline aperient should be given. The following is then given 
in the morning at 8, 8.30, and 9 a.m. : 

I^ Ext. filicis maris seth., fl., 5ij; 

Emuls. ol. ricini, §ij ; 

Ext. rhei fluid., ) _ _ 

Ext. aloes fluid., P^' ' ^^^' ""' 

Syrup., 3vj. 

M. Sig. : Give in three doses. 

After the worm is out it should be examined in order to determine 
whether the slender portion with the small head has passed. A second 
dose of the tapeworm remedy may be given in a day or two if the worm has 
not passed and the patient is not weak from the effects of the first dose. If 
children vomit the medicine, it may be given by stomach tube. Salicylic 
acid is also used as a tapeworm remedy. 
It is given in divided doses, forty grains 
in one day, followed by a dose of castor 
oil. 

TUBERCULOUS PERITONITIS IN 
CHILDREN 

The infection of the peritonaeum may ^^ 
come about by way of the circulation or ^K° . ffl|f f 
from the gastroenteric or genitourinary ^B '""'M^m * 

tract. It may readily take place in chil- 
dren without an antecedent history of 
tuberculosis. ^^^£^A 1 

The diagnosis of tuberculous peri- ^H^^^L ^ m 
tonitis is based upon the abdominal ^HHl^Bk! A r-, 
symptoms, such as distention, pain, and 
disturbed bowel action, and the presence 
of fluid and loss of weight, and is made 
by exclusion, except in those cases in 
which the tubercle bacilli are found, and 
then the diagnosis is positive. A febrile 
rise of temperature of an irregular type 
has been found in all cases under careful 
observation. There is nothing charac- 
teristic about the temperature curve. Fig. 62.— Tuuerculols Peritonitis 
The fluid is an inflammatory exudate. «^ '^^^'^ ^^""^ Standing. 

Cases of chronic non-tuberculous ser- 
ous peritonitis present usually the features of an ordinary ascites, the abdom- 
inal fluid being free, whereas it is usually not free in the tuberculous variety. 
It is rare to find the tubercle bacilli by microscopical examination of puncture 
fluid. In doubtful cases the opening of the abdomen is indicated and will do 
no harm. Paroxysmal pain in the abdomen of children, in the absence of 
chronic appendicitis or abdominal fluid, is not indicative of tuberculous dis- 
ease and is frequently overcome by dieting and attention to and irrigation of 
the bowels. (See Worms, Intestinal Indigestion, Membranous Enteritis, etc.) 




150 



PEDIATRICS 



A routine test with tuberculin in human beings in the present unsatis- 
factory state of our knowledge of its action is hardly justified. 

Clhiical Varieties of Tuberculous Peritonitis. — 1. Chronic tuberculous 
ascites (miliary form) ; 2. Fibrocaseous tuberculous peritonitis; 3. Fibroadhe- 
sive tuberculous peritonitis; 4. Tuberculous peritoneal tumors; 5. Tubercu- 
lous ulcer of the intestine and appendix 
with adjacent miliary tuberculosis of 
the peritonaeum; occasionally purulent 
peritonitis from perforation of a tuber- 
culous ulcer. 

Treatment. — In the present state 
of our knowledge, simple laparotomy is 
the best treatment for tuberculous 
peritonitis. The opening of the ab- 
domen is, as a rule, followed by an ar- 
rest of local disease symptoms, and it 
may be followed by a disappearance 
of the tuberculous deposits on the per- 
itonaeum, as shown by certain cases in 
which the abdomen has been opened 
for some reason or other for the second 
time. The futility of medicinal treat- 
ment was experienced by the writer in 
a series of forty-one cases which were 
subsequently treated by operation. 
Where some form of medication is fol- 
lowed by improvement or cure, one 
must not forget that spontaneous cures 
have also been reported and observed 
in cases presenting all the clinical evi- 
dences of the disease; After opening the abdomen direct medication by 
iodoform emulsion or flushing with normal salt solution may be employed. 
Finally, the indication is an early operation, which is no doubt of very 
great benefit to the patient when the tuberculous process is limited to 
the peritonaeum. As regards the establishment of a complete cure, one 
may be somewhat sceptical, because of the persistence of mild abdomi- 
nal symptoms, of irritative catarrh or inflammation in the bronchi, lungs, 
pleurae, and intestines, in cases which remain under observation after 
operation. If at the time of operation we have coexisting tuberculosis of 
the lung or pleura, the ultimate results are unsatisfactory, although some 
improvement usually takes place for the time being. 




Fig. 63. — Tuberculous Peritonitis 

AND Hernia. 

Apparent Cure after Herniotomy. 



DISEASES OF THE RESPIRATORY TRACT IN CHILDREN 

INTRODUCTORY REMARKS 

This group of ailments centres around the symptom cough. Cough 
is a reflex phenomenon usually due to irritation in the respiratory tract. 
The tendency to " colds " and cough is most marked in anaemic, rhachitic, 



CATCHING COLD 



151 



\ 



r 



syphilitic children and in children who are housed and who sleep in over- 
heated rooms, in children of tuberculous antecedents, and in children who 
have chronic malarial disease, or who are suffering from other chronic ail- 
ments. In addition to such general underlying conditions we have local 
irritation to take into consideration, such as is furnished by the presence 
of swollen follicles (follicular pharyngitis) or of adenoid vegetations or of 
enlarged tonsils and peribronchial tuberculous glands. 

These statements apply to the entire group of respiratory ailments, and 
in the management of children subject to " colds " and cough all these points 
must be taken into consideration. It will not suffice simply to order an 
expectorant or cough mixture. Children should sleep in cool rooms and 
not be burdened by heavy woolen underwear, in which they are apt to per- 
spire on the least exertion. It is 
important to keep the feet warm 
by wearing good stockings, but 
it is bad policy to keep the neck 
protected by furs and wraps, 
except in extreme weather. In 
neurotic children and adults wc 
frequently observe a "nervous 
cough " which we are unable to 
locate. In the absence of local 
and constitutional causes, fresh 
air and a cool sponge bath daily 
are to be recommended for such 
conditions. Hot drinks are good 
expectorant mixtures, and a 
water trip, or absence from the 
dust laden city air is the best 
cough mixture, even in mild 
febrile cases of long standing. 
For harassing cough at night a 
few drops of paregoric with wine 
of ipecac may be appropriate. 

Adenoids and large tonsils 
must be removed, and swollen 
follicles should be cauterized. 
In protracted cases one or two 
doses of quinine may be given as a therapeutic "feeler " for malaria, even 
in cases in which the blood is free of Plasmodium malarice, and occasionally 
potassium iodide will promptly check a harassing or long standing cough. 

CATCHING COLD 

The rationale of the causation of the ordinary " cold " by reason of 
localized or general chilling of the body is made plausibly clear by recent 
studies on the bactericidal power of the blood of animals exposed to cold. 
It has been found that by chilling the svirface it is possible to reduce the 
number of antibodies in the blood to a very marked degree. This means 




Fig. 64. — Tuberculous Peritonitis with Cys- 
tic Accumulation oi' Fluid. (Operation.) 

No relapse or symptoms after four years. 



152 PAEDIATRICS 

that the body is deprived of a goodly proportion of its defensive weapons, 
and therefore under such conditions it easily falls a prey to infections of 
all sorts. On the other hand, repeated exposure to slight degrees of cold 
brought about an increase of antibodies, and this observation therefore 
affords a theoretical justification of the practically approved methods of 
"hardening " the body by h3'drotherapeutic and other methods of training. 

Simple Acute Rhinitis, Pharjmgitis, Laryngitis, Tracheitis, and Bron- 
chitis are names given to the mild infectious catarrhs of the upper and 
lower respiratory tract, according to localization. 

The Symptoms are sneezing, lacrymation, coughing, moderate fever, 
loss of appetite, and a sensation of chilliness with mucopurulent secretion 
in the terminal stage. The mild forms last two to three days; the severe 
forms one to two weeks. 

A persistent nasal catarrh with excoriation at the nostril is strongly 
suggestive of diphtheria, and a culture should be made and antitoxine 
administered if the Klebs-Loeffler bacillus is found. 

Mild overlooked nasal diphtheria with a free pharynx and subsequent 
measles and laryngitis and ultimate diphtheritic croup form a clinical sequence 
which has surprised many a colleague. The possibility of syphilis should 
also be borne in mind. 

In coryza there is a nasal discharge. In pharyngitis the pharynx is 
red and dry and there is hoarseness. In rhinitis, pharyngitis, and laryngitis 
we should examine carefully for diphtheritic patches in the nose and throat. 
Bronchitis and the measles eruption go hand and hand, as do pharyngitis 
and scarlet fever. 

Treatment of a "Cold." — In uncomplicated mild cases of catarrh 
in the upper respiratory tract the children are put to bed and a laxative is 
administered. Hot and cold drinks are given and a fluid diet or fever diet 
is appropriate. To wash away secretions and disinfect the nasopharynx, 
a few drops of salt water are poured into the nostrils by means of a spoon, 
every three to four hours, or an albolene spray may be used for the nose and 
throat. Older children may take three to five grains of saccharinate of 
quinine or euquinin. The management of laryngitis with a croupy cough 
and stridulous breathing is discussed under Croup. 

The general hygienic management has been outlined in the introductory 
remarks. If children do not promptly recover, the urine should be examined 
and a general careful examination should be made, to detect if possible any 
further complications. It will not suffice to order cod liver oil and trust 
to luck, as in the good old days. Incipient tuberculosis can often be recog- 
nized by a careful examination, and frequently can be arrested and cured 
by energetic hygienic and dietetic management. 

The Clinical Features of Acute Bronchitis in Children 

Bronchitis is an inflammation of the mucous membrane of the bronchi. 
It may be unilateral, but is usually bilateral. It may be primary and 
represent an extension of a " cold " beginning in the upper air tract, and 
it may be secondary to or accompany many other forms of disease and 
is a common ailment in ill nourished and rhachitic children. 



BRONCHITIS AND BROxNCHOPNEUMONIA IN CHILDREN 153 

Symptoms. — In the mild form of bronchitis we observe cough, acceler- 
ated breathing, a moderate rise of temperature, loss of appetite, vomiting, 
restlessness, and often a wheezing respiration. In the severe forms, which 
cannot be distinguished clinically from bronchopneumonia, the dyspnoea 
is more marked. The respiration may be 60 to 80, with slight cyanosis. 
The chest is filled with coarse moist rales. Attacks of respiratory failure 
are observed and occasionally we have the clinical evidence of acute 
emphysema. 

The PROGNOSIS is favorable except in the severe form, which is often 
fatal to young infants, whereas older children usually get well. 

Differential Points. — Bronchitis may be the first symptom of measles 
and whooping cough and may indicate an irritation from inflamed and 
enlarged peribronchial glands. 

Treatment. — A mild bronchitis is managed like any other form of 
" cold." In the winter the child is put to bed in a room heated to 70° F. and 
a change from one room to another is advisable. The patient should 
receive an enema and a warm bath and should have cool water to drink. 

Diet. — Soft diet for older children. Infants take their usual liquid 
nourishment. As soon as the febrile stage is over children should be taken 
out of doors in fine weather. The nasopharynx should be kept moist by 
instilling ten drops of salt water into each nostril several times a day. In 
tardy convalescence, two or three grains of quinine in a teaspoonful of 
compound elixir of taraxacum may be given once or twice for the purpose 
of counteracting any underlying malarial factor. To check a harassing 
cough, five to ten drops of paregoric may be given once or twice, particu- 
larly at night. In the severe form of bronchitis the treatment is identical 
with that of bronchopneumonia. 

Poultices, jackets, and inhalations are probably useless and are not 
employed by the writer. The protracted cough during the convalescence 
stage is favorably influenced by a change of air and mild cauterization of the 
nasopharynx with a five per cent solution of argentic nitrate. An albolene 
spray applied through the nostrils often relieves local irritation and cough. 

Throat Coughs of Children, — Hypertrophied tonsils cause a constant 
cough, which becomes severely spasmodic at times. 

Adenoids cause a frequent hacking sort of cough, as in beginning tuber- 
culosis, due to the postnasal catarrh present in such cases. 

Cough due to Granular Pharyngitis and its accompanying catarrh is 
characterized by its onset with emotional disturbance, as at the beginning 
of laughing or crying. Frequently the cough is of a dry and rasping char- 
acter and the little patient is compelled to clear his throat frequently, with 
the expectoration of small pellets of gray sputum. 

The treatment is directed to the cause. 

BRONCHOPNEUMONIA IN CHILDREN (Catarrhal Pneumonia, 

Capillary Bronchiitis) 

Definition. — An infectious, diffuse pulmonary catarrh or inflammation 
without the typical " hepatization " which is characteristic of lobar pneu- 
monia. The portal of entrance for the various microbes responsible for 
this condition is the respiratory tract. 



154 



PEDIATRICS 



The predisposing factors are, in the first place, the general ones appli- 
cable to all microbial infection or disease, viz.: lowered vitality from any 
and all causes (malnutrition, rhachitis, exhausting diarrhoeas, malarial, and 
any, cachexia, and the breathing of impure dust and germ laden air). The 
breathing of pure cold air is not in itself a source of danger. Children who 
live and sleep in overheated and ill ventilated rooms are apt to suffer from 
all forms of infectious respiratory troubles. House infections in schools, 
school dormitories, and overheated and carpeted living apartments are 
daily occurrences among the rich and the poor alike. It is at all times diffi- 
cult and frequently impossible to escape infection of some kind or other; 
but the time is ripe for abandoning the superstition and ignorance which 
invite infection by fostering and perpetuating the fear of breathing cold 
air. Rational precautions against catching cold need not be neglected. 

Our knowledge of the bacteriology of bronchopneumonia is only frag- 
mentary. The pneumococcus, staphylococcus, and streptococcus are 



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tifi"^ 1 





Fig. 65. — Temperature Curve in a Case of Septic Bronchopneumonia in a Child, 

Ending in Recovery. 



principally in evidence, and the streptococcus infection appears to be the 
most septic and fatal. The secondary forms of bronchopneumonia com- 
plicating measles, whooping cough, scarlet fever, diphtheria, ileocolitis, 
influenza, and other diseases are all mixed infections. 

Symptoms. — When the onset is sudden, or as a sudden exacerbation in 
bronchitis, we observe high fever, cough, rapid and embarrassed respiration, 
and sometimes cyanosis. The temperature curve is not characteristic 
as in the lobar variety of pneumonia. In some instances there is a low 
febrile temperature and the pulse is generally rapid and becomes weak with 
increased prostration. Convulsions are not frequent; late convulsions 
are ominous. Delirium and restlessness are observed. The digestion is 
poor, and tympanites with dyspeptic diarrhoea and vomiting complicates 
the situation. The urine is scanty and high colored and may show albumin, 
as in any other acute*infectious disease. 

Physical Signs. — Fine subcrepitant rales and sibilant, rough, coarse, 
and musical rales may be heard over one or both sides. Small scattered 
areas of dulness or atelectasis come and go, with bronchial breathing over 
the dull areas. To bring out the auscultatory signs the children must be 



BRONCHOPNEUMONIA IN CHILDREN 155 

made to cry. In some of the protracted and severe forms of broncho- 
pneumonia the physical signs are almost nil, and in others the physical signs 
approach very nearly to those of the lobar type of pneumonia. 

Clinical Varieties. — 1, Mild or moderately severe primary broncho- 
pneumonia, often beginning as a mild bronchitis, with convalescence in 
eight to ten days; 2, Septic form, lasting from three to eight weeks; 3, 
Rapidly fatal form of from one to three days' duration; 4, Bronchopneu- 
monia secondary to other infections and of a varying degree of severity. 

Termination and Sequelas. — 1, Complete recovery; 2, Death; 3, Chronic 
bronchopneumonia with and without emphysema; 4, Empyema; 5, Tuber- 
culosis of the lungs; 6, Complications affecting the pleura, the meninges, 
the pericardium, the gastroenteric tract, the ear, and the kidneys. 

Prognosis. — Bronchopneumonia is a serious disease in children, and 
particularly in acute septic cases and in exhaustion from previous illness. 
In bottle fed young infants in baby hospitals the mortality is above 50 per 
cent ; in private practice, even among the poor, the mortality is far less. 

Prophylaxis. — All cases of pneumonia should be isolated, and where a 
house infection is suspected it is best to remove the well children to another 
house for the time being. A child with bronchitis should have a few drops 
of salt water poured into the nostrils from a spoon three times a day and 
should live in good air. A trip on the water is a better tonic and expectorant 
than any form of medication. Difficult feeding cases in young infants 
should not be kept in children's hospitals for any length of time, on account 
of the patients' proneness to contract bronchopneumonia. 

Treatment. — A child suffering from bronchopneumonia should receive 
a warm mustard bath of 100° F. and an enema or laxative and be put to 
bed in a well ventilated and sunny room. 

Diet. — Infants should receive the breast or bottle and plenty of boiled 
water between times. Older children may take food as here outlined: 

Beef broth and egg, eggnog, soup, cereal decoctions, toast in milk, lady 
fingers, custard, milk, ice cream, apple sauce, beef jelly, boiled water 
(cooled), ginger ale, cocoa, pineapple juice, orange juice, mint tea, green or 
black tea. Tropon, which is about 90 per cent protein, may be given in 
water, tea, or milk. 

In acute febrile conditions, the food must be fluid or semifluid and in 
a form which will not overtax the feeble digestive apparatus or leave a 
large residue for decomposition and local irritation in the bowel. 

Hydrotherapy. — Fever with great cerebral restlessness is best man- 
aged by some form of hydrotherapy. A temperature of 104° or even 105° 
is in itself no cause for anxiety, but, if coupled with restlessness and fleet- 
ing delirium, should receive special attention. An ice cap or cold coil to 
the head and flushing the bowels with cool water will reduce the tempera- 
ture. A warm mustard bath at 100° F., reduced to 90° or 80° while the 
patient is in the bath, is a safe measure. A child may remain ten minutes 
in the water, and should be rubbed during the time, then wrapped in 
blankets, and put to bed and warm water bags applied to the stockinged 
feet. A cool sponge bath (water and alcohol) applied under a blanket 
is a safe procedure. Very restless children become more quiet if a cold 
compress is placed around the chest and renewed every two hours. Such 



156 PAEDIATRICS 

a compress appears to act as a mild counterirritant, and when applied 
elicits a few deep inspirations, which are desirable. The writer has not 
observed any special benefit from the wearing of an oil silk jacket or a 
poultice. Such a contrivance is more soothing to an anxious mother than 
to a feverish child. 

As the nasopharynx is apt to become dry in feverish children with 
rapid breathing, it should be moistened three or four times a day by pouring 
into each nostril ten to twenty drops of a one per cent salt solution by 
means of a spoon. An albolene spray is also useful for this purpose. 

When the tongue is heavily coated, it is wise to aid digestion by ad- 
ministering hydrochloric acid. The following prescription is well suited 
for this purpose: 

I^ Acid hydrochloric, dilut., 3 j ; 

Ess. pepsin., 3ij- 

M. S. : A teaspoonf ul four times a day. 

For frequent vomiting the following prescription may be administered: 

I^ Tinct. iodini, gtt. x; 

Aq. menthse, 3 vj ; 

Syrup, sacch., 3ij. 

M. S.: A teaspoonful every two hours until vomiting is checked. 

It is a good rule to give only one medicine at a time and if possible to 
get along without drugs. 

Rectal Alimentation. — In all septic fevers in which digestion is 
below par we notice a loss of strength with emaciation, in which event rectal 
alimentation may be useful. From two to four ounces of an oil emulsion 
should be injected into the rectum three times a day. 

Before giving a nutritive enema, the bowels should be flushed and 
cleansed. Rectal alimentation will probably not have much influence in 
counteracting the pernicious action of bacterial toxines on the nerve 
centres. 

General Treatment. — Stimulants and expectorants are indicated when 
the pulse shows weakness, and when a loose rattling cough is accompanied 
by prostration or the " typhoid " state. Camphor, ammonia, ether, strych- 
nine, and nitroglycerine may be given. In bronchopneumonia secondary 
to some other disease stimulation may be necessary from the beginning. 
(For stimulation, see chapter on General Therapeutics in Disease.) * 

Urgent dyspnoea is best combated by means of heart stimulants and 

expectorants and mild general massage. Artificial respiration is not to be 

■overlooked in the management of such a condition. When the patient is 

cyanotic and the surface veins are filled, venesection may be helpful in older 

children. (See Venesection.) 

Oxygen inhalations are much in vogue. Their precise value in our 
remedial paraphernalia is unknown, but they appear to do no harm. 

When the acute stage of bronchopneumonia is passed and the disease 
continues in a mild way, it is well to remember that syphilis and chronic 
malarial disease are frequent substrata of acute infectious disorders. 



ACUTE LOBAR PNEUMONIA IN CHILDREN 157 

Therefore it is rational even in the absence of the Plasmodium in the blood, 
to give a few doses of quinine or iodide of potassium as a " feeler." 

I^ Quinin. sulph., gr. x; 

Elix. tarax. comp., §j. 

M. Sig. : A teaspoonful twice a day. 

I^ Potass, iodid., 5ss. ; 

Spt. ammon. anisat., 5ss.; 

Syrup, simplicis, 3ij ; 

Aquae, ad, 5ij. 

M. Sig.: A teaspoonful four times a day. 

Potassium iodide is, moreover, an expectorant, and may be given per 
rectum, and quinine carbamide may be given in solution subcutaneously 
if necessary. When convalescence is tardy, the patient should be drugged 
as little as possible and should receive the stimulating and invigorating 
effects of fresh air. One should not hesitate to send feeble children 
with a slight rise of temperature to the seashore and have them take short 
trips on the water, stopping all medication. In tuberculous bronchopneu- 
monia intermittent high fever continues and the children waste away. 
In the absence of a sputum examination this condition must be inferred 
from its clinical manifestations. 

Chronic bronchopneumonia with and without acute attacks of " asthma " 
and progressive emphysema is frequently met with in children's practice. 

In such cases much can be accomplished by careful management of the 
nasopharyngeal and digestive tracts. Such cases require pure air and 
cool sponging. The patients must have regular bowel action and must 
not be tortured by being compelled to wear thick flannels; protection from 
cold temperatures is best gained by means of heavy outer garments. Medi- 
cation is useless, but the potassium iodide expectorant mixture is indicated 
in intercurrent attacks of mucopurulent bronchitis. 

ACUTE LOBAR PNEUMONIA IN CHILDREN (FIBRINOUS, OR 
CROUPOUS, PNEUMONIA) 

This is an acute infection of the lung by the pneumococcus. The portal 
of entrance is naturally the respiratory tract. There are three stages in 
the course of this form of pneumonia: 1. Congestion; 2. Hepatization; and 
3^ Resolution. Recovery from the disease is usually ushered in by a 
critical sudden defervescence. 

The mortality from lobar pneumonia in children is greatest in the first 
year of life, and it is not high in children above two years of age, a vast 
number of cases terminating in complete recovery. Mortality statistics in 
lobar pneumonia are not trustworthy, on account of the difficulty of dis- 
tinguishing between lobar pneumonia and bronchopneumonia. 

Symptoms. — The onset is sudden or occurs during a mild attack of 
bronchitis with vomiting and chill. 

Pain, which is not always present, is often referred to the abdomen. 
Pain in the right side of the abdomen, with tympanites, simulates appen- 



158 PAEDIATRICS 

dicitis. The temperature is from 103° to 105° in the general run of cases. 
The pulse is full, strong, and from 120 to 130. The respiration is from 
30 to 50. The cough is short and occasionally painful ; there is no expectora- 
tion. The face is flushed and there is restlessness, with a coated tongue, 
loss of appetite, and thirst, also mild or active delirium, and convulsions 
(occasionally). Leucocytosis is generally to be observed. About the 
seventh day the temperature drops to normal or subnormal and marked 
improvement is manifest. Convulsions indicate a violent onset, but not 
necessarily a grave prognosis. Convulsions at the time of resolution are 
ominous and indicate meningeal complications or circulatory failure with 
inanition of the brain. 

Clinical Varieties in Children. — The usual localization is in the inferior or 
middle lobe, to which the inflammation is limited or from where it may spread. 

Apex pneumonia is also common and may be accompanied by severe 
delirium, sometimes convulsions. The cough is short and gagging. 

Central Pneumonia. — The localization is deep seated, and it may take 
from four to five days before the localization is clearly demonstrable. 

Double Pneumonia. — This is a grave condition with urgent dyspnoea, 
but not so fatal as in adults, particularly if one side clears up before the 
other. In one-sided pneumonia the unaffected lung of the other side 
may be congested, which condition gives the mistaken idea of a true double 
pneumonia. 

Abortive pneumonia differs in the ordinary form only in duration and 
rapidity of defervescence, which may take place at the end of two or three 
days. This form gives rise to the mistaken idea that pneumonia can be 
aborted by drugs now in use. 

Wandering pneumonia is characterized by steady advance of consolida- 
tion from lobe to lobe. 

Massive Pneumonia. — The physical signs simulate effusion because the 
air cells and bronchi are filled with exudate. 

Physical signs, in acute lobar pneumonia in children. — 

1st Stage : Congestion. — Weak respiration sounds, crepitant rales on 
deep inspiration or expiration. 

2d Stage : Consolidation. — Dulness on percussion, increased vocal 
fremitus, bronchial breathing. The latter may be temporarily absent when 
a large bronchus is filled. In children dulness, fremitus, and bronchial 
breathing may be observed in pleuropneumonia with effusion. 

3d Stage : Resolution. — The physical signs are practically the same as 
in the first stage. The rales are moist. 

Disease Conditions Simulating Lobar Pneumonia. — Hypostatic conges- 
tion and pulmonary oedema give dulness at the base, weak breathing 
sounds, rales, and dyspncea. The history of the case and the absence of 
bronchial respiration and of the typical high temperature will usually clear 
up a doubtful case. 

In bronchopneumonia the physical signs are those of a diffuse bronchitis 
with scattered small areas of dulness. It is sometimes impossible to dis- 
tinguish one form from the other. 

Acute tuberculous pneumonia is not an unusual manifestation in young 
children of tuberculous parentage. The history, the high temperature 



ACUTE LOBAR PNEUMONIA IN CHILDREN 159 

curve, often remittent, the dyspnoea with cyanosis, and the loss of flesh 
will lead to the recognition of this ailment. Its occasional massive lung 
dulness will give the impression of fliiid in the chest, but it is found to be 
absent on puncture. In infants a diagnosis between lobar pneumonia and 
bronchopneumonia is often impossible. The post mortem room shows 
frequent errors in this respect. 

Pleurisy with effusion in young children should not be mistaken for 
pneumonia, on account of the marked difference in the physical signs. In 
obscure cases a puncture will determine the presence or absence of fluid. 

Treatment. — We have at the present time no specific drug which will 
abort or cure lobar pneumonia. The disease is self-limited, usually ending 
in recovery, and medication plays a minor role in its nianagement. A 
child taken ill with pneumonic inflammation should receive a warm bath, 
at 100° F., an enema, or two to five grains of calomel, and should be put to 
bed in a well ventilated room, at about 68° F. A young child should receive 
the breast or bottle and plenty of cool boiled water to quench thirst. Older 
children are put on liquid diet: Beef broth and egg, soup, gruel, toast in 
milk, lady fingers, custard, stewed apples, milk, water, ice cream, ginger 
ale, pineapple or orange juice, tea or mint tea, tropon, cocoa, junket, calves' 
foot jelly. 

The appetite in acute febrile disease is always below par, and a change 
to peptonized food is in the vast majority of cases not called for. A few 
drops of dilute hydrochloric acid in sugar water three times a day will aid 
digestion, and this is a rational routine prescription in febrile and other 
disease for patients above one year of age. 

When the time for a critical drop of temperature has arrived and the 
fever continues, we must look for complications or we may recognize an 
extension of the pneumonic inflammation to adjacent territory or we con- 
clude that we have been mistaken as to the kind of pneumonia present. 
When dulness persists for several days, after the critical drop of temperature, 
it means delayed resolution or a pleuritic exudate. In delayed resolution 
the child should be carried into the open air daily or taken to the seashore 
or country; iodide of potassium may be given per rectum (five grains twice 
daily) in an ounce of warm water or by mouth. 

I^ Potassii iodid., 3ss. ; 

Spt. ammon. aromat., 5ss.; 

Syrup, simplicis, 5ij ; 

Aquae, ad, 5ij- 

M. Sig. : A teaspoonful every three hours in water. 

Children with tuberculous antecedents may take maltine and creosote. 

High temperature with cerebral restlessness is managed by hydrotherapy 
and the ice cap, not as a rule by drugs. While the patient is in the bath 
the temperature of the water may be reduced from 100° to 80° F. Sponge 
baths are serviceable in mild cases of pneumonia. 



160 PEDIATRICS 

Circulatory Failure and Stimulation 

In lobar pneumonia circulatory failure is due to sepsis and pulmonary 
obstruction combined. In general practice a moderate rise of pulse and 
temperature appears to be the indication for the administration of the 
various heart drugs in use at the present time. It is questionable whether 
early and promiscuous stimulation is in the interest of the patient. Un- 
fortunately, the indications for stimulation are by no means clearly under- 
stood, and no doubt in many instances we credit happy results to some 
particular drug or method, when the inherent reserve power of the heart 
alone is responsible for the recovery of the patient. Taking this view, it 
would appear a more rational plan to adopt enteroclysis for early stimula- 
tion, instead of drugs. 

Enteroclysis stimulates through the abdominal sympathetic and pro- 
motes kidney secretion and thereby elimination of septic products. More- 
over, it promotes intestinal absorption of water whenever the body craves it. 
Intestinal irrigation is performed with the aid of Kemp's double current 
flexible tube or a plain soft rubber catheter. The fluid used is a solution 
of salt ( 5j to 1 pint) at 110° F., and the flow is kept for ten minutes. Me- 
dicinal stimulation with alcohol, camphor, caffeine, strychnine, digitalis, or 
nitroglycerine may be employed in urgent cases in connection with entero- 
clysis, but in the majority of instances children get well without drugging 

PLEUROPNEUMONIA-PLEURISY WITH SEROUS EFFUSION 
AND PYOTHORAX IN CHILDREN 

GENERAL REMARKS 

Physical diagnosis as applied to the thorax gives such positive evidence 
of abnormal conditions that it would seem impossible to overlook a general 
or localized pleuritic exudate or be in doubt as to its presence or absence in 
a given case. It is, however, a daily occurrence for mistakes to be made 
in this direction, for faulty conclusions to be arrived at from a faulty in- 
terpretation of symptoms and physical signs, and for the presence of pus 
within the thorax not to be recognized. 

The infection of the pleura is occasionally primary, but takes place 
principally through direct extension from the bronchi or lungs and from 
purulent affections of other organs, and through a metastatic process. 
External injury followed by infection also takes place; exposure to cold 
should be looked upon merely as a predisposing agent. 

Pleuropneumonia with effusion is found in children of all ages. The 
diagnosis is made by the physical signs to be discussed under Empyema 
and by exploratory puncture. The symptoms are those of severe pneumo- 
nia, the dyspnoea being particularly distressing. The prognosis is grave. 
Very young children rarely recover. In older children the outlook is not 
so unfavorable. 

Pleurisy with Serous Effusion. — Primary pleurisy is infrequent in chil- 
dren. Its onset is insidious, with fever of an irregular type and with pain. 
Shortness of breath is observed as soon as the effusion sets in. The 



PLEUROPNEUMONIA AND PYOTHORAX 161 

signs of fluid in the chest are discussed under Empyema. Friction sounds 
may be heard above the level of the fluid. The character of the fluid is 
elicited by puncture. 

Prognosis. — Most cases end in recovery. 

Pyothorax. — The vast majority of empyemata are secondary to pneu- 
monia, pulmonary gangrene, pulmonary tuberculosis, pertussis and erup- 
tive fevers with catarrhal or fibrinous pneumonia, pericarditis or peri- 
tonitis, or are sequelae of rheumatic infection, infectious nephritis and 
perinephritis abscess, osteomyelitis, diphtheria and "croup," typhoid fever, 
gout, pyaemia, ulceration of the trachea, oesophagus, and stomach, appen- 
dicitis, or abscess of the liver or spleen. 

Pyothorax developing during typhoid fever is not at all rare; pyothorax 
developing after pneumonia following intubation for diphtheritic stenosis 
is exceedingly rare. As to the time of year that most cases of empyema 
in children are observed, it is evident that cold and damp weather, which 
is the predisposing factor in bronchial and pulmonary catarrh and inflamma- 
tion, is also the predisposing factor in empyema. Thus, we see more cases 
in February, March, and April than in the nine other months of the year. 
The pulmonary type of influenza is responsible for quite a number of cases 
of empyema. Empyema is a common disease in children under five years, 
and it may be stated in a general way that one third of all pleuritic effusions 
in children are of the nature of pus or seropus. 

In gangrene of the lung and in pyopneumothorax due to traumatism 
a stinking, septic pus is found. Pus is frequently found streaked with 
blood. A sanguineous pleuritic exudate, such as is found in tuberculosis 
and occasionally observed as a complication in articular rheumatism, is 
very apt to become pus. Occasionally inspissated pus is found. A colloid 
substance representing inspissated serous exudate is very rare. Chylous 
effusion has been observed and mistaken for pus. The upper layers may 
consist of seropus, the lower layers of thick creamy pus; loose and adherent 
pseudomembrane is often found. Occasionally the quantity of pus ob- 
served does not exceed an ounce, and frequently it reaches one, two, or three 
pints. 

We have unilateral, bilateral, free, and multilocular encapsulated pyo- 
thorax, in which latter case one pus sac may be drained without emptying 
the other. The bilateral form may be primary or follow pulmonary gangrene, 
typhoid fever, tuberculosis, etc. The thoracic abscess may be interlobar, 
anterior, posterior, lateral, or located on the diaphragm. 

After these general preliminary remarks on the subject of pyothorax 
we will confine our attention to the diagnostic points, our consideration 
of which will embrace the physical diagnosis of fluid in the chest. A purulent 
fluid is distinguished from a serous fluid by the aspirating needle alone 
and not by any set of signs or symptoms. The presence of peptone in the 
urine in cases of pyothorax is by no means a distinguishing feature. Von 
Jaksch has found peptonuria in scurvy, in intestinal ulceration, in the third 
stage of pneumonia, and in syphilis. Furthermore, in making our diagnostic 
enquiries, we must always bear in mind the occurrence of hydrothorax, 
free or localized and sacculated, in consequence of disease of the heart, 
lungs, or kidneys. 
12 



162 PAEDIATRICS 

Subacute cases of pleurisy with irregular temperature curve, pain, 
cough, and dyspnoea due to effusion will be readily recognized by a careful 
observer. The change of a simple pneumonia into a pleuropneumonia is 
also not very difficult to recognize. Children with simple pneumonia 
cry readily and apparently without much effort or pain. A child with 
pleuropneumonia will give evidence of pain when it is handled and in crying. 
In pleuropneumonia the respiration is rapid and superficial and occasionally 
intercepted. Diaphragmatic respiration stops and the entire thorax is 
lifted in the efforts of respiration. 

The puzzling cases are the very acute ones in which, in the absence of 
expectoration, the initial symptoms of pneumonia and pleurisy in children 
are about the same, i. e., fever, pain, cough, rapid breathing, and dyspnoea, 
and where (1) critical defervescence takes place with dulness on percussion 
continuing, or (2) a continued irregular temperature curve extends over 
the second and third weeks of illness with marked dulness persisting. (See 
Unresolved Pneumonia or Effusion.) In such cases the question arises: 
Have we a pulmonary dulness to deal with or an effusion or both? And 
what is the nature of the effusion? Our decision is based on inspection, 
palpation, auscultation, percussion, and puncture. 

Examination. — Inspection. — Rational signs of fluid: 1, Lateral curvature 
of the spine; 2, Lack of movement of the affected side; 3, Bulging of the 
affected side; 4, Bulging or retraction of the intercostal spaces on inspira- 
tion; 5, Displaced heart; 6, Dyspnoea; 7, Cutaneous oedema; 8, Enlarge- 
ment of the subcutaneous veins; 9, Pallor of the skin. 

All these signs may be present or most of them absent in empyema; 
moderate dyspnoea on exertion is usually noticeable in pleuritic effusion, 
also bulging of the affected side when massive effusion is present. On deep 
inspiration the intercostal spaces become convex, but occasionally we notice 
a retraction or concavity of the intercostal spaces on inspiration in the 
presence of fluid. Pallor and loss of appetite are generally noticeable in 
cases of pyothorax. A displaced heart is not commonly seen, but must 
necessarily be noticed in massive effusion on the left side. Cutaneous 
oedema and enlarged veins are occasionally present. Lateral curvature 
of the spine is seen in cases of long standing, and where a chronic sinus 
has existed we find marked curvature, a deformed chest, a shrunken side, 
and a depressed shoulder. 

Fever. — Fever in pyothorax is irregular and sometimes absent, as in 
cold abscesses in other parts of the body. 

Palpation. — Rational signs of fluid: 1, Bulging of the lower inter- 
costal spaces on inspiration; 2, Absence of vocal fremitus. 

If the finger tips are pressed upon an intercostal space, an outward 
bulging will be felt on inspiration in the presence of fluid. This sign, how- 
ever, is not always present in hydrothorax or pyothorax, and is generally 
absent in the presence of small exudates or in cases of rhachitic thorax 
with a very narrow intercostal space. 

Vocal fremitus is usually absent over a fluid, and educated finger tips 
will map out a small localized sacculated exudate with nicety. Bacelli's 
sign, a diminished fremitus in the presence of thick exudates, cannot be 
relied upon to distinguish serum from pus. In some instances fremitus over 



PHYSICAL DIAGNOSIS OF FLUID IN THE CHEST 163 

a fluid is present, but diminished as compared with the sound side or as 
compared with the fremitus over the region of the compressed apex of the 
hmg of the affected side. This is readily understood if we remember that 
vibrations may be communicated to the chest wall by means of localized 
pleural adhesions. In order to enable the examiner to note the pres- 
ence or absence of fremitus, the children must be made to cry. The cry is 
usually weak. 

Auscultation. — Rational signs: 1, Absence of respiratory murmur; 2, 
Weak voice, cry, or cough; 3, Noisy respiration. 

The absence of the respiratory murmur is a classical sign of the presence 
of fluid in the thorax, but there are exceptions to this rule, as in the case of 
a consolidated lung with compression or occlusion of the bronchus. 

A thin layer of fluid surrounding the lower part of a lung will not obscure 
the breathing sounds^ When a thoracic abscess has been partly expecto- 
rated through a perforation into a bronchus, moist rales may be heard over 
the affected side, which is still dull on percussion. Tubular breathing 
may be heard over fluid, transmitted from a pulmonary dulness on the 
affected or the opposite side and due to compression or inflammation of 
the adjacent or underlying lung. Catarrhal pneumonia with pyothorax 
will give all the usual varieties of rales, and the same is true of hypostatic 
pneumonia or pulmonary oedema and pyothorax. 

Friction sounds are heard before and after exudation, but not over 
fluid. Diminished vesicular breathing, perceptible fremitus, and dulness 
speak for thickened pleura or membrane or new growth. In empyema 
the trachea may be so obstructed that inspiration and expiration are 
impeded and a noisy and croupy respiration is present. vEgophony is 
occasionally heard in the axillary line in the presence of large exudates. 
Pseudocavernous signs in the shape of amphoric tubular breathing are 
sometimes met with in children, suggesting the presence of tuberculous or 
non-tuberculous cavities in the lung. This phenomenon is particularly 
misleading when associated with the noise of the cracked pot on percussion. 
Bronchophony is heard over consolidated lung tissue, not over fluid. The 
voice and cry in empyema are weak; the cough is weak, short, and gen- 
erally moist. 

Percussion elicits flatness and marked resistance to the finger in con- 
ditions of fluid in the thorax. On the right side this merges into the area 
of liver dulness. A rhachitic flat chest or deformed thorax gives apparent 
dulness on percussion and occasionally misleads the examiner. Dulness 
of the posterior right thorax in infants is not always pathological, and is 
frequently due to compression by a large liver during forced crying. This 
dulness disappears during inspiration. A pathological dulness remains 
during inspiration and expiration. A consolidated lung, thickened pleura, 
thoracic new growth, hypostatic pneumonia, or pulmonary oedema shows 
dulness on percussion. A massive pneumonia with the bronchi plugged 
with fibrin may present an almost flat percussion sound and undue re- 
sistance to the finger; in such cases the increased fremitus will establish 
with great probability, but not with certainty, the absence of fluid. 

In the presence of a thin layer of fluid forced percussion brings out the 
percussion sound of the underlying lung. In copious exudates the flatness 



164 PEDIATRICS 

may reach the clavicle and extend beyond the sternal margin of the affected 
side. When the lung is pressed into the apex by a fluid, the lower area is 
flat on percussion with absence of breathing sounds and absence of fremitus, 
and in the apex over the compressed lung we find high pitch dulness, tubular 
breathing, and increased fremitus, also, occasionally, in a pliable thorax, 
we obtain the sound of the cracked pot on percussion just below the 
clavicle (pseudocavernous sign). In apex dulness, with absence of breath- 
ing sounds and absence of fremitus, a localized anterior abscess may be 
suspected. 

A marked resistance to the finger on percussion is of very great value as a 
diagnostic sign, and will often establish the presence of fluid. The degree 
of dulness and resistance on percussion depends principally upon the thick- 
ness of the layer of fluid. 

A marked displacement of neighboring organs is rarely found on per- 
cussion in children. In one case of pyothorax on the right side I found the 
heart beat in the left axillary line. The alteration in the height of fluid on 
change of position and the curved line of Ellis and Garland are indistinct 
manifestations in children. To appreciate the finer phenomena as elicited 
by percussion, it should be practised with the fingers only. 

Now, bearing in mind the variability of the physical signs and rational 
symptoms of fluid within the thorax, it is evident that occasionally in a 
given case the atiology is important in order to appreciate the physical 
conditions present. When an unresolved pneumonia is suspected and an 
empyema overlooked, we generally have a history of pneumonia with 
critical defervescence and a subsequent rise of temperature, with continued 
dulness on percussion. 

When we suspect fluid, we can prove its presence or absence best by means 
of the aspirating needle, and as regards the character of the fluid, this is es- 
tablished by the aspirating needle and in no other way. 

To make a probatory puncture the following should be observed: The 
patient is made bare to the waist and the site for puncture is cleansed with 
ether and 1-1,000 bichloride solution. The child is held firmly in the lap 
of its nurse and the arm of that side which is to be attacked is raised high 
and kept in this position, thereby securing a larger intercostal space. The 
physician firmly presses the tips of his left index and middle fingers into 
the selected space as a guide (not lower than the eighth interspace) and with 
the right hand, armed with a clean syringe and a rather large needle, punc- 
tures the interspace midway between the finger ti})s. The needle should 
be introduced from one to two inches, as the case may be, and the piston 
drawn out. The needle may now be pushed slowly forward or it may be 
slowly withdrawn. Lateral movements are not permissible unless the 
needle is in a pus cavity, for fear of tearing the lung tissue and producing 
pneumothorax or subcutaneous emphysema, several instances of which 
have come to my notice. 

If all signs point to fluid and none is found, a second and third puncture 
may be made. If the needle enters a pus sac, pus will show, if it is only 
a drop. Should the needle be arrested before entering a pus cavity or be 
pushed beyond a pus sac or enter dense adhesions or a new growth or a 
thick pseudomembrane (pus membrane), pus will not show, A gelatinous 



EXPLORATORY PUNCTURE IN PLEUROPNEUMONIA 165 

exudate or thick inspissated pus will not pass through a very fine needle. 
A serous exudate mixing with a few drops of a disinfecting solution within 
the syringe may cause the aspirated fluid to look turbid and be mistaken 
for seropus, therefore the exudate removed should be examined under the 
microscope. 

When the needle is withdrawn the puncture wound is at once secured 
with sticking plaster or thin rubber tissue made sticky by means of a drop 
of chloroform or ether. Puncture on the right side should be made so as 
not to injure the diaphragm or liver. If the puncture is made not lower 
than in the eighth interspace, such injury is improbable, as the liver and 
diaphragm are pressed downward by the weight of the exudate. If punc- 
tures are made in the manner described, there is not the slightest danger 
of infecting the thoracic cavity thereby. When a serous exudate becomes 
pus it is through infection from within. 

When the presence of pus is shown by the needle, the treatment indicated 
is that of any abscess, whether it be unilateral, bilateral, free, or localized. 
A deep lung abscess with adhesions of both pleura? is treated like a localized 
empyema. In abscess of the mediastinum we find a fluctuating tumor at 
the border of the sternum. In purulent pericarditis we should strike pus 
over a pyriform prsecordial dull area with no evidence of cardiac shock. 
Occasionally the symptoms of purulent pericarditis are very obscure and 
misleading. A peripleuritic abscess of metastatic origin may be mistaken 
for empyema. 

Lung abscess, lung hernia, thoracic new growths, and echinococcus of 
the thorax have been observed in children and mistaken for empyema. 

Very interesting from a diagnostic and practical point of view are cases 
of multilocular pyothorax. In these cases the pyothorax is readily ascer- 
tained with the needle, but the multilocular and encapsulated pus sacs 
are first recognized during or after the operation, and make incision in 
various places necessary. The following case has come under the writer's 
notice: 

A young lad had contracted amoebic diarrhoea in Central America and 
come North for treatment. There was flatness over the posterior aspect 
of the thorax on both sides, and the liver dulness was enlarged. A puncture 
through the eighth interspace on the right side gave pus of a chocolate 
brown color. A puncture at the seventh interspace of the same side gave 
a clear watery liquid, and the same watery effusion was found on the left 
side. The condition was clearly one of hepatic abscess which had perforated 
through the diaphragm into the thoracic cavity and was encapsulated. In 
addition there was hydrothorax of both sides. 

The pulsating character occasionally observed in empyema is due to 
forcible heart action. 

Termination. — Empyema in children usually ends in complete recovery 
if operated upon in time. When the lung expands and the pus cavity heals 
by granulation, a thickening of the pleura with adhesions results, as shown 
by slight dulness and diminished breathing over the affected side. In 
some cases a fistula will remain for a considerable length of time after 
operation, with ultimate recovery, or death ensues from tuberculosis, 
amyloid degeneration, or exhaustion. 



166 PEDIATRICS 

Treatment of Pleuropneumonia. — The management of pleuropneumo- 
nia is the same as in pneumonia. When fluid is suspected and found by 
puncture, its removal (if pus or seropus) is immediately indicated. (See 
Treatment of Empyema.) If only clear serum is found, its removal by 
aspiration or incision through the intercostal space is indicated only in 
urgent dyspnoea. When puncture reveals a turbid fluid containing pus 
elements, a single incision in the intercostal space will let out the fluid, 
and a shred of iodoform gauze may be introduced into the pleural cavity 
to act as a drain. This procedure gives immediate relief, and the infant 
will be in a better condition to stand other operative interference (resection 
of a rib) should such become necessar3\ 

In pleurisy the patient receives a warm mustard bath and a stiff dose 
of calomel and is put to bed. A cold compress is placed around the «hest 
and renewed every hour or two. The diet is the same as in pneumonia. 
Although medication plays no role in the management of pleurisy with 
serous effusion, it is an undoubted fact that some cases do remarkably well 
under the administration of sodium salicylate (three to five grains four 
times a day). If malaria or syphilis is suspected as an underlying condition, 
iodide of potassium may be given per rectum, or the syrup of iodide of iron 
by the mouth, or quinine by the mouth. 

The removal of fluid by aspiration or incision and drainage is indicated 
only when its massive accumulation endangers life from pressure upon the 
heart and lungs. If no absorption of fluid takes place after four weeks, 
the removal of a few ounces by aspiration appears to start spontaneous 
absorption. 

When tuberculosis is suspected as an underlying cause, the young 
patient should lead an outdoor country life with the hope of throwing off 
the disease. 

Treatment of Pyothorax. — Resection of a portion of a rib under anaes- 
thesia and drainage of the abscess cavity is the treatment for empy- 
ema. Irrigation of the abscess cavity is not usually practised unless the 
pus is foul and stinking. If the patient is in collapse, anaesthesia is dan- 
gerous. In such cases it is better to cut rapidly through the intercostal 
space and relieve pressure by allowing some of the fluid to flow out. Hy- 
podermic stimulation and enteroclysis may tide the patient over the critical 
period and subsequently resection of a rib may be done under ether in 
the usual way. 

Chronic empyema necessitates further surgical treatment, after which 
the patient should be sent to the mountains, to the seashore, or to a con- 
valescent home for fresh air treatment until the discharge ceases and the 
wound is closed. Patients should not be detained in city hospitals for 
any length of time after operations for pyothorax, as recovery is more rapid 
in the country or at the seashore. 

Where operative interference is not resorted to, recovery may take place: 

1. By perforation into a bronchus with expectoration of pus. 

2. By perforation between two ribs, usually in the fifth interspace, or 
both these conditions may be present. 

3. Recovery by gradual absorption of a small exudate of pus. Such 
recovery is rare. 



FEVER FOLLOWING OPERATIONS FOR PYOTHORAX 



167 



A perforation into a bronchus may exist without allowing the exit of 
pus until intrathoracic pressure has been diminished by aspiration or 
incision. An external perforation may be cribriform, and a sound introduced 
may strike a rough rib (denuded of its periosteum by pus erosion) , suggest- 
ing caries of the spine or rib. The pointing external pus sac may be pulsat- 
ing in character. Perforation into the oesophagus has been reported, also 
cases of perforation through the diaphragm, the pus passing down behind 
the peritonaeum as in cases of psoas abscess. 

Secondary abscesses following pyothorax are a constant occurrence, 
such as otitis media, purulent pericarditis, phlegmon of cervical region, 
periostitis, purulent meningitis and peritonitis, abscesses of the scalp, 




Fig. 66. — Fever Curve in Tuberculosis of Lung and Unresolved Pneumonia Com- 
pared IN Cases of Empyema. 

gluteal region, eyelids, etc. Such secondary pus deposits are found in cases 
that have been operated upon as well as in neglected cases. 

As a rule the pleuritic exudate is in contact with the general circulation, 
as shown by the presence of drugs (chemicals) in the exudate. 

The reinflation of a collapsed lung exposed to the pressure of the atmos- 
phere through an opening in the pleural cavity is a paradox. 



The Significance of Fever following Operations for Pyothorax 

It may be stated that a completely apyretic course after empyema 
operations is exceptional. Assuming that in a given case of pyothorax 
the proper surgical procedure has been accomplished, we might expect, where 
the temperature has been high before operation, a fall of temperature 
and a normal or nearly normal temperature curve during convalescence. 
It is well known, however, that in a large number of cases a rise from the 
normal takes place at once or at various times during the further course 
of the disease, and as this fever temperature almost invariably indicates 
an extension of the disease or a complication of some kind, grave or trivial, 
it becomes a matter of great importance to correctly interpret such fever 
and remove any source of irritation if present, and, if possible, to remedy it 



168 PAEDIATRICS 

before the patient is exhausted. The correct interpretation of fever after 
an empyema operation is in some instances extremely simple and in others 
extremely difficult, and it will not suffice to inquire simply into the matter 
of drainage and, if such appears satisfactory, to overlook other factors 
equally important. 

The following are some of the causes for fever temperatures after opera- 
tion for pyothorax: 

Faulty drainage, slipping of a drainage tube into the thoracic cavity, 
intoxication with iodoform or carbolic acid, retention of urine, constipa- 
tion, secondary extrathoracic abscess, eruptive fevers, wound infection, 
malarial fever, extension of the original inflammation to the other side 
or to other parts, unresolved pneumonia, coexisting tuberculous broncho- 
pneumonia, nephritis as a complication, deep seated multilocular abscess, 
mild or severe general sepsis, and irritation from a drainage tube too long 
in place. 

Thus a rise of temperature may mean very little, but it always indicates 
something which we should endeavor to locate and correct. The successful 
management of pyothorax is not alone a matter of incision and drainage, 
but calls for accurate clinical investigation and observation. A carefully 
kept record of temperature furnishes valuable evidence as to the underlying 
cause of fever. 

WHOOPING COUGH; PERTUSSIS 

This is a contagious disease due to a microorganism of unknown nature 
which probably finds foothold in and about the larynx and by its presence 
provokes a spasmodic reflex cough. It attacks children of all ages, and 
young children are particularly susceptible. If, after an exposure, two 
weeks pass without the development of a cough, the probabilities are that 
the disease has not been contracted. The average duration of the spas- 
modic stage is one month. It is not definitely known whether or not per- 
sonal contact is necessary for infection. It starts as a catarrhal bronchitis, 
then turns into whooping cough with vomiting spells, and gradually dimin- 
ishes in severity. After subsiding, it may start up again after a so-called 
fresh " cold," and last for from three to four months, particularly in winter. 

There are no characteristic physical signs by which we can diagnosticate 
pertussis, except the "whoop." In infants whooping cough is often fatal; 
in children over four years it is seldom fatal. During the paroxysm there 
is severe heart strain, and a small number of the patients have chronic 
emphysema of the lung after recovery. In others the vesicular emphysema 
is not permanent. 

The complicating phenomena and clinical varieties are: Mechanical 
visible haemorrhages; bronchopneumonia and emphysema with and without 
fever; convulsions (asphyxia or intracranial haemorrhage); indigestion, 
diarrhoea, vomiting; heart strain with albuminuria; paralysis in whooping 
cough of cerebral or peripheral origin (infrequent) ; stomatitis and sub- 
lingual ulcer. Sublingual ulcer may be due to the friction of the tongue 
against the teeth or it may be of contagious or parasitic origin. 

Management. — The best treatment for whooping cough is the fresh air 
treatment. 



WHOOPING COUGH; PERTUSSIS 169 

Children with pertussis must be quarantined, but not confined to the 
house. The patient must Hve out of doors. A warm place at the seashore 
is the best location. The writer has known violent whooping cough to 
cease in three days on board an ocean steamer. If possible, the children 
should be changed from one cool sleeping room to another. The rooms 
in which they are confined should be well ventilated at all times day and 
night, and the air should not be vitiated by burning a "cresolene " lamp. The 
nasopharynx should be lubricated and kept clean by instilling mild salt 
water solution into each nostril four times a day, or by spraying albolene 
into the nose and throat. 

The only drug which has given the author any satisfaction in treating 
whooping cough is antipyrine, of which one, two, or three doses (gr. i, ii, 
or iii) are given at night. Opium or belladonna may be given at the same 
time in exceptionally violent cases. In complicating bronchopneumonia 
with much secretion, camphor and hyoscyamus as a stimulant and expecto- 
rant may be given, also warm baths. Systematic compression of the thorax 
(artificial respiration) aids in expelling the secretions and is indicated in 
cyanosed children. For the management of convulsions in whooping cough, 
see Convulsions. 

A paroxysm of whooping cough can be cut short by pressing the lower 
jaw forward and downward, as in asphyxia. Mother, nurses, and other 
attendants should be instructed in its use in order that the oncoming 
attacks, especially at night, may be arrested. Ozone inhalations in whoop- 
ing cough have been employed. Such inhalations undoubtedly have a 
distinct curative effect as regards the duration and severity of the disease. 

The following quotation is from a communication on the subject (Trans- 
actions of the American Pcediatric Society, 1892): Seven cases of pertussis 
were treated with ozone inhalations. The ages of the children ranged from 
eighteen months to seven years. Each case was well marked and of average 
severity. The cases were first treated in the second and third week of 
illness, at which time the paroxysmal cough is well developed. Two to 
three inhalations of fifteen minutes each were given daily, and all the cases 
were discharged after two weeks' treatment, except one case which was 
treated four weeks. No drugs were given, but salt water was dropped 
into the nose three times a day. The improvement became manifest 
after the first three to four inhalations. The children slept better during 
the night after inhaling ozone, and the youngest child under observation 
usually went to sleep after each inhalation. Unfortunately an efficient 
ozone generator is too expensive for general use in the homes of patients." 

In very severe cases of whooping cough with frequent spells, much 
vomiting, and rapid loss of flesh and strength, intubation may be tried 
after all other rational treatment has been unavailing. 

Pseudo, or False, Whooping Cough.— A throat cough with a whoop is 
a frequent sequela of influenza and yields promptly to local treatment. 
Cauterization with 2 per cent nitrate of silver solution and albolene or salt 
water spray through the nostrils into the pharynx are to be employed. 



170 PAEDIATRICS 



THYMUS GLAND; ENLARGEMENT AND ABSCESS 

The thymus gland is situated in the anterior mediastinum ; its function 
is unknown. It is small in the new-born, increases in size up to the end 
of the second year, remains unchanged until about the end of the tenth 
year, and diminishes in size until puberty, when it entirely or nearly disap- 
pears. When the thymus gland is enlarged it gives a substernal dulness 
on percussion, which is more readily elicited when the child is held hori- 
zontally, face downward, and percussion is practised from underneath. This 
dulness may also be due to enlarged peribronchial glands, in which case 
the predominance of percussion dulness is usually on one side, and other 
swollen lymph nodes are present in the lower region of the neck. The 
thymus gland may be present as an arched elastic swelling in the median 
line above the sternal notch. It may become hyperaemic or haemorrhagic 
from the various causes which induce congestion, and it may suppurate 
or participate in a tuberculous process. 

Enlargement of the thymus interferes with respiration and circulation. 
It may give rise to an inspiratory stridor often mistaken for laryngospasm. 
Sudden death from an enlarged thymus may have for its cause compression 
of the air passages or compression of the large vessels leading from the heart. 
These deaths are a mystery without a post mortem examination. The 
following case will give a fair idea of "sudden death in a case of enlarge- 
ment of the thymus." Intra vitam the infant was occasionally slightly 
cyanotic and had spells of rapid and laborious breathing. On two occasions 
it had convulsive seizures. Auscultation revealed a loud systolic murmur 
at the base of the heart with the valve sounds clear and distinct. The 
murmur was not transmitted in any direction. The infant died and the 
autopsy showed, as was suspected, a large thymus gland measuring two 
inches in length and one inch across. The lower pole of the gland com- 
pressed the large vessels in such a way as to cut off the circulation. 

A case of thymic tracheostenosis with substernal abscess was observed 
in a girl of two. The enlarged thymus gland could be mapped out by 
percussion. No improvement took place as regarded embarrassed respira- 
tion after administering mercuric inunctions and potassium iodide for about 
four weeks. Subsequently a rise of temperature was noted and the sub- 
sternal percussion dulness became more marked. An x ray picture showed 
a dense and a light shadow. Thymic enlargement and abscess formation 
were suspected and operative interference was decided upon. The child 
died under chloroform anaesthesia after the first few whiffs. The autopsy 
revealed a very large thymus gland and abscess. 

Treatment. — If enlargement of the thymus can be detected or is 
suspected calomel may be given in divided doses followed by a saline 
cathartic or potassium iodide (5ij ad 5j) may be administered by local 
inunction twice a day. In the event of an acute attack of suffocation, 
tracheotomy and intubation may be thought of. Resection of a part of an 
enlarged thymus gland and the removal of the entire gland has been done 
and the thymus has also been sutured to the sternum. 



DIPHTHERIA 171 



ENLARGED BRONCHIAL LYMPH NODES 

The rational signs of enlarged bronchial lymph nodes are those of com- 
pression, i. e., pain, dyspnoea, cyanosis, and oedema, but all such character- 
istic signs may be absent, as the following case will show: A girl of four was 
admitted into a children's hospital with the diagnosis of bronchitis. There 
was no elevation of temperature, no pain, no dyspnoea, and the heart and 
kidneys were free. A few rales could be heard on auscultation over the 
sternum. On the morning following her admission she was playing with 
other children in the ward when she suddenly began to complain of pain 
in the neck, and almost immediately became cyanotic and asphyctic. As 
a large calibre O'Dwyer tube did not relieve her dyspnoea, a low tracheot- 
omy was performed also, without giving relief. The obstruction was 
evidently in the lungs, and she died in a few minutes. At the autopsy 
both bronchi were found plugged with a cheesy material which came from 
a tuberculous bronchial lymph node situated above the bifurcation of the 
trachea, which had perforated and ruptured into the trachea. As long as 
the child was under our observation there were no symptoms pointing to 
such a condition, and the cheesy gland was in an unfavorable position 
for surgical interference. The specimen was presented to the American 
Psediatric Society at Washington, D. C, in May, 1900. When a diagnosis 
can be made, general hygienic management and the administration of 
potassium iodide are indicated. 



DIPHTHERIA 
INTRODUCTORY REMARKS 

Diphtheria is an acute infectious and contagious disease caused by the 
Klebs-Loeffler bacillus. The primary manifestations can be recognized 
at the portal of entrance in the nasopharynx or elsewhere. The secondary, 
or constitutional, symptoms are due to the absorption of toxines produced 
by the growth of microbes upon or within the mucous membrane, wherever 
lodged. The contagium is principally in the secretions from the nose and 
throat. For the method of preparing smears and glass preparations and 
swab cultures, see Laboratory Aids to Diagnosis. 

Diphtheria is communicable by direct or indirect contact as long as 
the bacilli are present in the various discharges from the throat, nose, ear, 
and other parts, and any unhealthy condition of the nose and throat pre- 
disposes to the infection. 

The incubation period varies, and it is possible for the germs to remain 
dormant in the mouth for an indefinite period and finally infect the body 
whenever the mucous membrane is weakened, receptive, or damaged. The 
formation of a pseudomembrane is the most constant lesion in diphtheria, 
but virulent infection may take place without membrane formation. 

The acceptance of the Klebs-Loeffler bacillus as the specific causative 
factor in diphtheria has made it necessary to give a name to membranous 
sore throat in which the bacilli are not found, but in which various cocci 



172 



PEDIATRICS 



are invariably present. This variety is at present called pseudodiphtheria; 
and some modern textbooks therefore speak of primary and secondary 
true diphtheria, and primary and secondary pseudodiphtheria} Although 
the mortality of pseudodiphtheria is not so high as that of the Klebs- 
LoefHer variety, still it is a very dangerous disease, and may be followed by 
paralysis and death, and inasmuch as we cannot distinguish clinically one 
variety from the other, and inasmuch as valuable time is lost in waiting for 
a culture test — which, by the way, is not always conclusive or final — every 
attempt to adjust treatment in accordance with the bacteriological clas- 
sification must be looked upon as a failure in the present state of our 
knowledge. 

While fully cognizant of the scientific and practical value of bacterio- 
logical research, we must confess that failure to clear up doubtful cases 
by cultures, and in good time, is a daily occurrence. Moreover, it is well 
known that in localities in which diphtheria is endemic the majority of 

cases eventually prove to be a 
mixed infection ; consequently 
the physician will be wise to look 
upon all acute throat affectio.ns in 
children, attended with fever and 
swelling of the lymph nodes, or 
upon membranous rhinitis with- 
out fever, or upon hoarseness with 
slow progressive stenosis, as sus- 
picious of diphtheria, and treat 
them accordingly. The bacterio- 
logical diagnosis of diphtheria 
.may be made in several hours 
by means of Loeffler's glucose 
blood serum and the incubator; 
still, to wait even a few hours for a bacteriological diagnosis is not wise. 
The culture test should be looked upon as a confirmative one, and nothing 
more. In tuberculosis, gonorrhoea, malaria, etc., the microscope establishes 
a positive diagnosis, after which we may institute rational treatment, but 
in diphtheria our specific treatment comes first, the microscope afterward. 

Another point worthy of brief consideration is the difficulty of distin- 
guishing clinically between follicular tonsillitis and diphtheria. As recog- 
nized by Dr. A. Jacobi more than thirty years ago, no amount of experience 
will enable the physician to distinguish between the two affections. What 
looks like a tonsillitis to-day may be a virulent diphtheria to-morrow; such 
cases should be isolated and treated as diphtheria. If a subsequent exami- 
nation proves the contrary, no harm has been done. In practice, the phy- 
sician who acts in accordance with these views will have more success in 
the management of such cases than he who poses on an ultra-scientific 
pedestal, waits for the culture test in diphtheria, and writes death certificates. 
Clinical and Characteristic Varieties of Diphtheria. — Diphtheria runs 
its course as a mild case, a septic case, or a stenosis case; but we can never 

' Another form of pseudodiphtheria is Vincent's angina with superficial and deep 
necrosis of tissue. 




Fig. 67. — Hocrehold Reflector. 
(From Pa>diatrics, 1901). 



DIPHTHERIA 173 

determine at the onset whether a case will progress favorably or terminate 
fatally. Its characteristics are the formation of a membrane, the presence 
of fever, indurated lymph nodes in the neck, sepsis, and laryngeal steno- 
sis. In membranous rhinitis and membranous laryngitis there is usually 
no fever. 

The following clinical varieties will be met with in practice: 

1. So-called follicular tonsillitis. 

2. Primary diphtheria of the tonsils and pharynx. 

3. Primary nasopharyngeal diphtheria. 

4. Primary nasal diphtheria; also called membranous rhinitis, or 
diphtheria larvata, 

5. Primary laryngeal diphtheria (membranous croup). 

6. Diphtheria without membranes (simulating simple angina), and a 
virulent form without membranes. 

7. Secondary diphtheria, following measles, scarlet fever, pertussis, etc. 

8. Diphtheria in young infants. 

Symptoms and Diagnosis. — The onset may be gradual or sudden, 
with fever, vomiting, anorexia, foetid breath, pain, delirium, dysphagia, 
and tumefaction of the lymph nodes. The membrane in true as well as in 
pseudodiphtheria presents many variations from a thick and cheesy, to 
a thin and veillike deposit; occasionally the surface appears as though 
smeared over with pus, and frequently we notice an infiltration of the 
mucosa without detachable membrane. The latter form may persist for 
weeks if antitoxine is not used, and if the local treatment is at all harsh 
and irritating. 

Virulent septic diphtheria without membranes, with very high fever, 
incessant vomiting, and a very rapid pulse, with or without delirium, is fatal. 
The throat is of a dusky brown red color. 

Diphtheria in the anterior nares gives very few symptoms: a running 
nose, excoriation at the nostrils, and snuffles, but no fever. This may go 
on for weeks, when an extension into the nasopharynx or larynx is manifest 
by other additional or subjective symptoms. The Germans call this form 
diphtheria larvata, and in all such cases a culture will show the true state 
of affairs. Ordinary thrush (Oidiiim albicans) can hardly be mistaken for 
diphtheria, but diphtheria of the mouth may be mistaken for stomatitis, and 
patches of leptothrix are frequently called diphtheria, particularly when 
associated with tonsillar inflammation, painful and swollen lymph nodes, 
and fever. Leptothrix patches will be found protruding from the crypts 
or margins of the tonsils, and are very difficult to scrape away; they also 
resist the action of various caustics to a remarkable degree, and sometimes 
make repeated scrapings and cauterization necessary. Mucosis of the 
uvula and palate may be mistaken for diphtheria and a bacteriological test 
will distinguish between diphtheria and the tonsillar ulceV of Vincent. 

Prophylaxis and Immunity. — Although the contagiousness of diph- 
theria is well established, it must be borne in mind that it is not so readily 
transmissible as scarlatina and some other infections. Moreover, that it 
can readily be prevented. At the present time the prevention of the spread 
of the disease is quite beyond the control of the central government. For 
information on municipal control, school hygiene, school inspection, isola- 



174 PEDIATRICS 

tion hospitals, and general and local disinfection, the reader is referred to 
the various articles on prevention of the spread of contagious diseases in 
this book. 

Personal Prophylaxis and the Nasopharyngeal Toilet. — The 
proper management of the nasopharynx in children and adults is one of the 
most important subjects in practical medicine. The nasopharynx is the usual 
site of entrance of diphtheria, and to this locality the preventive measures 
must be directed. In a contribution to the proceedings of the New York 
Academy of Medicine in 1884 the writer showed that chronic nasal catarrh, 
adenoid vegetations, enlarged tonsils, and carious teeth favored diphtheria 
infection, and that in the absence of such conditions the instillation of a weak 
salt or alkaline solution into the nose morning and evening would prevent 
diphtheria in those exposed or prone to contract it. The general practitioner 
should see to it that in all children coming under his professional care 
adenoids, if present, are removed by the post-nasal forceps and curette, 
that hypertrophic tonsils are resected, and that carious temporary teeth are 
filled or extracted. 

The Nasopharyngeal Toilet consists in the instillation into each nos- 
tril, by means of an ordinary teaspoon, of a spoonful of salt water, 1 per 
cent, morning and evening (at bedtime and on rising), as the children lie on 
their backs, with the nose tilted up and the mouth open. The liquid does 
not wash through at once; some of it remains in the various recesses of 
the nasal cavity, and is eventually sneezed out or swallowed. In this way 
putrescible matter and bacteria are washed away (mechanical antisepsis). 
Where additional chemical antiseptic action is desired, a 1 to 5,000 mercuric 
bichloride solution, or Labarraque's solution, 10 per cent, or a rose colored 
permanganate of potassium solution should be employed. 

The nasopharyngeal toilet, carried out in the way described, is indicated 
for (1) all healthy children from one year up who live in infected localities, 
and (2) for all healthy children directly exposed to diphtheria infection. 
It is also the best method of local treatment in all cases of diphtheria, in which 
instances it should be resorted to every two hours ; moreover, it is the most 
satisfactory local routine treatment in all diseases in which diphtheria fre- 
quently sets in as a complication, e. g., in scarlatina, measles, and pertussis; 
furthermore, it is a necessity before and after tonsillotomy and all operations 
on the nose and throat. This method is far superior to gargling, and in 
many forms of reflex cough, also in cough of tuberculous origin, it is far 
superior to nauseating expectorant mixtures, and in all forms of febrile 
disease in which the nasal secretion becomes dry, crusty, or hardened, 
half a teaspoonful of salt water instilled into each nostril affords much relief. 
The nasopharyngeal toilet not only does not provoke middle ear and acces- 
sory sinus complications, but, according to the experience of the writer, 
apparently prevents them. 

Immunity. — Specific and direct immunity is secured for those exposed 
to diphtheria by means of antitoxine. The period of immunity varies 
from three to six weeks, which is sufficient for all practical purposes in times 
of epidemics or house infection. Aside from the reports which come to 
us from abroad, we have reliable reports from various hospitals for the 
treatment of children's diseases throughout the country which go to prove 



DIPHTHERIA 175 

the absolute value of antitoxine as an immunizing agent. The immunizing 
dose is 500 units, and all exposed children should receive this quantity. 

The curative and immunizing properties of diphtheria antitoxine are 
established facts. According to recent careful and unbiassed investigations, 
the mortality in primary diphtheria has been reduced two thirds, and the 
protective power of diphtheria antitoxine extends over a period of from 
three to six weeks or more. With an agent so powerful for good at our 
command, the question naturally arises: Do we or do we not make the 
best use of our new therapeutic acquisition? The writer suggests^ a new 
use for this agent by advocating an immunizing injection for young school 
children once or twice during the school year, for instance, in November 
and February, with the hope of preventing infection from primary diphtheria 
or croup, and, furthermore, with the hope of lessening the mortality of the 
severe forms of scarlatina and measles, a large percentage of such cases 
being complicated by diphtheria from the beginning or in the course of 
the disease. 

It is well known to the experienced medical practitioner that cases of 
scarlatina which show a complicating diphtheria from the onset are of a 
very grave type. In such cases we often observe an overwhelming sepsis 
with delirium and circulatory failure. In scarlatina with complicating 
diphtheria setting in after the first week the septic symptoms are never 
so acute and urgent. 

In measles we observe diphtheria as an early or late complication, but 
the most important diphtheria complication of measles is diphtheritic 
croup. The mortality from scarlet fever plus diphtheria and from measles 
plus diphtheria is quite high, and the writer is of the opinion, based on 
clinical experience, that this mortality can be markedly reduced by means 
of protective inoculations of diphtheria antitoxine. Such prophylactic 
management will have no effect upon pure and simple scarlatina or measles, 
but will certainly create more or less immunity as regards grave diphtheritic 
complications, or, in other words, turn a grave disease into a milder disease. 

Treatment. — (a) By antitoxine. (6) Supplementary treatment. 

(a) Antitoxine. Dosage. Indications for. 

The treatment for diphtheritic inflammation consists in the early 
and proper administration of reliable antitoxine, supplemented by the 
nasopharyngeal toilet. The time for discussing the pros and cons of anti- 
toxine treatment is past ; the specific curative power of this remedial agent 
is an established fact. Behring's contention, that if antitoxine is used early 
the mortality from diphtheria will not exceed 5 per cent, is borne out by 
the reports of competent clinicians all the world over. Opposition to any- 
thing so radically new as Behring's discovery is one of the associating features 
in the evolution of scientific medicine. Vaccination and antiseptic surgery 
stand in evidence of this fact. Any practitioner who studies the collective 
investigation reports for 1896 and 1897, on antitoxine for diphtheria and 
croup in private practice, issued by the American Psediatric Society, and 
fails to use antitoxine because he "does not believe in it," should not be 
entrusted with the management of a case of diphtheria, and the practitioner 

' Transactions of the American Padiairic Society, 1903. 



176 PEDIATRICS 

who thinks a case is mild and waits for severe symptoms before using 
antitoxine, utterly fails to grasp the situation and will frequently be 
disappointed. 

Indications for Antitoxine. — Antitoxine is indicated in doses of 500 
units for immunizing exposed persons, and in doses of from 2,000 to 4,000 
units to combat the disease. 

2,000 units for very young children. 
2,000 to 4,000 units for older children. 
3,000 units in croup cases. 

It should be employed at the earliest possible moment, and the dose 
repeated the following day and subsequently as often as is necessary. 
The dosage is expressed in units, and not in the serum quantity; the prepa- 
ration having the highest number of units in the least quantity of serum, 
and from an absolutely reliable source, is to be preferred. The injections 
are made in any region where a fold of skin can be picked up — the skin, 
the hands of the physician, and the syringe must be clean. Any syringe 
will answer, but the best syringe is one made entirely of glass, and it is 
low obtainable in the shops. 

The writer also advises the injection of a curative dose of antitoxine 
in every case of scarlet fever coming under his notice, because this disease 
is frequently complicated with diphtheria, and he also administers a cura- 
tive dose in cases of measles and whooping cough if the throat shows the slight- 
est appearance of a pseudomembranous patch. It would appear rational to 
give an immunizing dose in puerperal cases where a diphtheria case exists 
in the same house; also to children on whom an operation is to be done in 
the nose or throat and where the culture test shows the presence of diph- 
theria bacilli without clinical symptoms. Antitoxine is also indicated in 
diphtheria of the eye, which is, fortunately, very rare. The more common 
croupous conjunctivitis is not to be confounded with eye diphtheria, in 
which the eyelids are phlegmonous and hard. 

The antitoxine rash, which is noticed in a certain number of cases, 
has no very characteristic features and may readily be mistaken for scarlet 
fever or measles rash; its appearance is usually not heralded by a rise of 
temperature and increase of other symptoms. As regards the combined 
use of antistreptococcic and antidiphtheritic serums in cases of mixed infection, 
no positive advice can be formulated at the present time. 

(6) Local Supplementary Management. — The local treatment of diph- 
theria must be mild. Swabbing the throat in diphtheria is harmful, and 
should not be practised. Solutions used as gargles do not reach the naso- 
pharynx; the spray is only to be employed in cases in which force need not 
be used, e. g., in docile children. The best way to cleanse the nasopharynx 
is to pour the liquid into the nose from a spoon; if the nose is partly or 
almost completely stopped up, a blunt piston syringe or a Davidson's or 
fountain syringe must be employed. In septic cases the irrigation is best 
done as the children lie on the side, in order to avoid any sudden strain and 
collapse. For the majority of cases, instillation by means of a spoon will 
suffice. This may be done every hour or two, and if necessary day and 
night, according to the severity of the case. If syringes are used, the 



DIPHTHERIA 177 

stream should be directed horizontally, and not upward. Syringes should 
not be used if bleeding follows each irrigation. 

The following liquids may be employed: Salt water, a teaspoonful to 
a pint, permanganate of potassium, a rose colored aqueous solution, mercuric 
bichloride in water, 1 to 10,000, listerine, 1 to 10, lime water, alum water, 
5 per cent, Labarraque's solution in water, 1 to 20, 2 per cent ichthyol 
solution in water. 

Peroxide of hydrogen has shown itself to be an active irritant, and 
aids the spread of diphtheria ; it should therefore not be used in this disease 
unless largely diluted. Any of the above mentioned liquids may be used as 
a gargle when children are able to gargle. Excoriations at the angles of the 
mouth and at the nostrils usually heal under camphor ice. 

Antitoxine, with mild local treatment and jvidicious stimulation, will 
suffice for ordinary cases seen in good time; but as cases will come under 
observation in which valuable time has been lost in temporizing with house- 
hold remedies, the physician will not be spared the management of various 
complications, which will now engage our attention. 

Medication. — The local antiseptic power of a teaspoonful of medicine, 
as it glides over the tongue and down the oesophagus, is practically nil. 
The yellow chlorate of potassium and iron mixture and the mercuric 
bichloride mixture will not be necessary where antitoxine can be had, 
and should under no circumstances be given to a patient with an irritable 
stomach. As an aid to digestion the following mixture is efficacious: 

I^ Ess. pepsin., 5ij ; 

Acid hydrochloric, dil., 5ss. 

M.S.: A teaspoonful four times a day. 

In septic cases, five drops of the tincture of chloride of iron may be given 
every four hours. 

Stimulation. — Whiskey, American Tokay wine, champagne, coffee, 
strychnine, gr. jq, three times a day; camphor, gr. 4^ to 1, three times a 
day; benzoate of sodium and caffeine, dose, gr. 1 to 3, also subcutaneously, 
dissolved in water; camphorated oil, 5 to 15 drops, subcutaneously. When 
the stomach is irritable, stimulating drugs may be given subcutaneously 
or per rectum. 

Fever. — High temperature can be reduced by cold and lukewarm 
sponge and tub baths. (See General Therapeutics.) To give an antipyretic 
drug regularly every two or three hours is very bad practice; one or two 
doses in twenty-four hours, particularly at night, are serviceable. From 
3 to 10 grains of phenacetine with half a grain of caffeine, or lactophenin 
with caffeine in the same dose, may be given. Antipyrine is a safe anti- 
pyretic, and as it is soluble in water, from 3 to 7 grains may be given per 
rectum. In cerebral restlessness an ice cap is advisable. Quinine should 
never be given as an antipyretic in any but malarial disease. 

Vomiting. — In cases of incessant vomiting stop all internal medication 
and give only 1 to 2 drops of tincture of iodine in sweetened peppermint 
water every hour or two or wash out the stomach. 

DiARRHCEA. — In many septic conditions a mild form of diarrhoea may 
complicate matters. This can usually be checked, if necessary, by a diet 
13 



178 PAEDIATRICS 

of burnt flour gruel or cornstarch pap and by omitting milk food for a time- 
Should this not suffice, 5 grains of tannic acid or tannigen, given with choco- 
late, or i a grain of acetate of lead with sugar of milk, or ^ a grain of 
camphor with i of a grain of Dover's powder, will check the diarrhoea. 

Albuminuria and nephritis are frequent complications of diphtheria. 
A stiff dose of calomel and jalap, and one or two warm baths a day to pro- 
mote diaphoresis, will be the treatment in such conditions. In nephritis 
with dropsy, as a sequela of diphtheria, an infusion of digitalis may act as a 
diuretic by improving the circulation. 

Convulsions. — Initial convulsions indicate intense infection or nervous 
reflex irritability, for which an enema, a warm bath, and hydrate of chloral, 
gr. iij, and potassium bromide, gr. v, are indicated, per os or per rectum. 
Terminal convulsions, indicating heart failure and cerebral inanition, give 
an unfavorable prognosis. A warm bath and stimulants are here indi- 
cated: 5 drops of camphorated oil and 5 drops of ether subcutaneously 
every few hours. 

Dry Tongue. — The tongue is sometimes so hard and dry that pain 
and difficulty in swallowing result. For this condition glycerine and rose 
water, equal parts, applied with a brush, afford relief. 

Pseudomembranous conjunctivitis is occasionally seen in severe 
diphtheria cases. This readily yields to ice compresses and the boric acid 
spray. In true diphtheria of the eye, in which the eyelids are much swollen 
and indurated, antitoxine must be used in large doses. Fortunately, 
as has already been said, this condition is very rare. 

Otitis media, due to an extension of the septic process through the 
Eustachian tube, is frequently observed, but the earache is not nearly 
so intense as in ordinary otitis media, and rupture of the drumhead takes 
place readily. The ear should be cleansed with mercuric bichloride solution, 
1 to 5,000, or a warm boric acid solution with cocaine, or menthol in sweet 
almond oil ( 3i to 3jv) should be instilled. The drum membrane may 
require puncture. 

Hemorrhage from sloughing of the tissues is a very dangerous and 
distressing complication. If possible, the bleeding spot should be located 
by means of a strong light and directly cauterized with the actual cautery, 
lunar caustic, chloride of zinc, alum solution, or antipyrine and tannin. 
The styptic iron preparations are not so applicable, on account of the large 
grumous blood clots which invariably form. 

Phlegmon and induration op the tissues of the neck, with indis- 
tinct fluctuation of cervical lymph nodes, are best managed by a large 
incision through the entire dense and thick skin down to the glands. The 
latter are usually in a friable, spongy state with little pus spots scattered 
through the tissue, and can readily be broken up by pushing a blunt director 
or dressing forceps through the capsule and sweeping it around in various 
directions in order to break up the necrotic tissue. Make one abscess 
cavity which can readily be drained by means of iodoform or bichloride 
gauze under a moist dressing. The neighborhood of such a diphtheritic 
and gangrenous wound occasionally has an erysipelatous appearance, 
which usually subsides under the application of cold lead lotion. 



CROUP 179 

Pa'olysis and Ataxia Folloiving Diphtheria 

Postdiphtheritic paralysis may affect the general nervous system, the 
eye, ear, throat, etc. 

Paralysis of the soft palate is not rare. A stationary palate, a na al voice, 
and food regurgitation through the nose are the characteristic symptoms. 
For this condition, as well as for the temporary locomotor ataxia which is 
occasionally observed, we require fresh air, baths, massage, the interrupted 
current, and -^ oi & grain of strychnine, three times a day, by the mouth 
or under the skin. The antitoxine treatment has not made paralysis cases 
more frequent, nor does it appear to facilitate the recovery from such 
complications. A gradual paralysis of the respiratory muscles, including 
the diaphragm, as shown by a weak cry and rapid, superficial breathing, 
is a very serious condition to deal with, but may improve under stimulation 
and artificial respiration. 

In addition to the general treatment just announced, the cold douche 
and artificial respiration may do good. Cardiac arrhythmia in the wake of 
infectious disease is not infrequent and is mostly due to myocardial involve- 
ment, for which rest, hygiene, and rational diet and stimulation are to be 
employed. Sudden death from heart paralysis gives no chance for treatment. 
In all cases of septic diphtheria, early and proper stimulation may prevent it. 

The anaemia which is known to follow in the wake of diphtheria and other 
infectious diseases demands tonics, such as fresh air and iron. Broncho^ 
pneumonia and lobar pneumonia, thrombosis of veins and arteries, and othe^ 
remoter complications will come under observation, and will call for proper 
management. 

Diet. — Milk, Vichy, matzoon, kumyss, beef peptonoids, cornstarch, 
eggnog, custard, ice water, cream, farina, cocoa, eggs, raw meat, burnt 
flour soup, whiskey, California Tokay, coffee, tea, punch, iced champagne, 
pineapple juice, and tropon. The diet in diphtheria is of prime importance. 
The food should be nutritious and digestible. Forced feeding is proper 
in exceptional cases, but it is well to remember that children with febrile 
and septic disease have little desire for food, and that the stomach will 
resent all attempts at overfeeding. Somatose is soluble meat without taste 
or smell, and can be given with cocoa, milk, gruel, rice, etc. 

For rectal alimentation we inject a mixture of whiskey, egg yolk, beef 
peptonoids, and warm water or somatose in oil emulsion. 

Gavage will be indicated in exceptional cases. 

In regard to the question as to when it will be safe to send children 
who have had diphtheria back to school, we should judge by the culture 
test. Whenever this test cannot be employed we should wait at least 
three weeks from the disappearance of clinical symptoms, during which 
time the nasopharyngeal toilet should be diligently carried out. 

CROUP 

In practice we recognize (1) a rroupy cough without stenosis; (2) a 
catarrhal or pseudocroup with dyspnoea, and (3) true croup, in which the 
stenosis is progressive and frequently necessitates operative interference. 




Fig. G8. — liNTUUATioN Tube in Situ. (Skiagram.) 



CROUP 181 

The croupy cough is common in children with adenoid vegetations, follicular 
pharyngitis, or large tonsils; it usually begins at night and yields to the 
mildest treatment. A cloth wrung out of cold water, around the neck, 
salt water dropped into the nostrils, and a hot drink are all that is necessary 
for the time being, with subsequent curettage or cauterization of the swollen 
follicles in the pharynx. Emetics are not indicated, although very popular 
with that class of parents who delight in goose grease and turpentine. 

As a type of pseudocroup with dyspnoea, the croup of measles is character- 
istic. Here we have to deal with catarrhal laryngitis or oedema of the glottis, 
which rarely goes on to complete stenosis ; the treatment is the same as for 
"croupy cough." Only in extreme cases will local scarification of the 
oedematous tissues or intubation be necessary. Adrenalin chloride is 
capable of controlling oedema. It may be applied by means of a cotton 
applicator every hour. The so called true croup either is a primary mem- 
branous laryngitis or is secondary to diphtheria of the nasopharynx. In 
primary membranous croup the pharynx is pale and the temperature normal, 
and the onset is never sudden; hoarseness, aphonia, and stenosis come on 
gradually, whereas in pseudocroup the onset is generally sudden, the pharynx 
is usually congested, and there is fever. About 80 per cent of membranous 
croup cases are known to be cases of Klebs-Loeffler diphtheria; in about 
20 per cent this bacillus has not been found. True croup should, therefore, 
be quarantined as diphtheria. 

The secondary croup with stenosis is due either to an extension of the 
membranes downward or to the swelling and oedema of the tissues adjoining 
a diphtheritic patch. Urgent laryngeal stenosis, secondary to various forms 
of nose and pharynx diphtheria, is, therefore, not necessarily membranous, 
but the treatment is practically the same in both instances. 

Treatment of Croup with Urgent Stenosis. — Before the advent of anti- 
toxine the best treatment for true croup, before operation, was with mer- 
cury or calomel, internally, by inunction, or by fumigation, and it is well 
known to experienced physicians that intubation and tracheotomy gave 
better results when mercury had been administered. Mercuric bichlo- 
ride, gr. ^V, was given every hour for one or two days, or 20 grains of 
calomel were volatilized over a lamp, under an improvised tent, every 
three hours for from twenty-four to forty-eight hours. The spray and 
croup kettle have very little value, and emetics in any shape are productive 
of evil, as they sap the strength of the patient. Now that we have specific 
treatment, we shall not discuss in detail our former management of croup 
cases, because the best treatment of croup, before operation, can be men- 
tioned in one word — antitoxine. Here, again, I refer the skeptic to the report 
of the American Psediatric Society on laryngeal stenosis, which tells the 
whole story, reflecting, as it does, the experience of hundreds of physicians 
and sifting the evidence in a judicial manner. Briefly, the report says: 
Before the use of antitoxine 27 per cent of intubation patients recovered; 
now V3 per cent recover. Sixty per cent of stenosis cases do not require 
operation if antitoxine is used in time, and an early use of antitoxine will 
lower the mortality of intubation cases still more. 

In every case of acute progressive stenosis 2,000 to 3,000 units of diph- 
theria antitoxine should be administered at once, and the dose may be 




Fig. 69. — Intubation Tube in Situ. (Skiagram.) 



INTUBATION AND TRACHEOTOMY 



183 



repeated in from twelve to twenty-four hours, and so on, until relief is 
manifest. As soon as the stenosis becomes less urgent, and the cough 
somewhat loose, the main danger is over, and camphor, gr. ^, or spir. am- 
moniffi, aromat., gtt. x, may be given as an expectorant and stimulant, 
four times a day. The same management should be resorted to in secondary 
stenosis following scarlet fever, measles, pertussis, nasopharyngeal diph- 
theria, or so called tonsillitis, together with the nasopharyngeal toilet, as 
before described. When antitoxine fails to check a progressive stenosis, 
the time for operative interference is close at hand. The proper time for 
the operation is a matter of experience; the physician should not wait until 
the patient is cyanosed and the pulse intermittent. 

INTUBATION AND TRACHEOTOMY 

Intubation is the art of introducing tubes into the larynx and removing 
them at the proper time. In combination with antitoxine, intubation is 
one of the greatest blessings at the disposal of the physician. Dr. J. 




Fig. 70. — O'Dwyer's Intubation Set. 



O'Dwyer, of New York, is the inventor of our present method of tubing for 
croup. The instruments he devised have been in general use since 1886, 
and although a number of modifications have been suggested, none has 
come to the writer's knowledge which is in any respect an improvement 
on those used in the original method, with the exception of Denhard's 
gag, which is universally used. Many of the modifications are useless 
or bad. The tubes now in use have a smooth coating of hard rubber, to 
prevent incrustation. The operation of intubation and extubation is not, 
in itself, difficult; but every one contemplating becoming a safe operator 



184 



PEDIATRICS 



should practise the operation on the cadaver. Its modus operandi cannot 
be learned from reading. Colleagues with a short and thick index finger 
have some difficulty in learning to tube properly. 

How to Operate. — Remove the child's clothes, except the undershirt, 
and wrap the child securely in a towel from the shoulder down, secured 
by safety pins. Place the child upright, facing the operator, in the lap of 
the nurse, who sits upright in a common straight backed chair. The arms 
of the patient are to be firmly held below the elbow; the child's legs are 
clasped between the knees of the nurse. The assistant stands behind the 
chair, holds the child's head firmly between the palms oi his hands, and when 
the gag is inserted includes it within his firm grasp. The position of the 
child should be as though it hung from the top of its head. The operator 
now inserts his index finger, hooks up the epiglottis, and inserts the tube 




Fig. 71. — O'Dwyer's Intubation Instruments. 

in the funnel-shaped entrance to the larynx by elevating the handle of the 
introducer. The tube is then gently pushed home. While loosening and 
withdrawing the obturator, the head of the tube is held in place by the tip 
of the index finger in the throat, and a gentle push may be given to place 
the tube well into the larynx. The introducer must be kept in the middle 
line, and the child must not be allowed to slip down in the nurse's lap. 



INTUBATION AND TRACHEOTOMY 



185 



The gag must be properly adjusted and firmly held. Any carelessness in 
carrying out these details will result in failure to introduce the tube. 

It may be in place to dwell briefly upon some important points as re- 
gards feeding and medication, duration of wearing the tube, intermittent in- 
tubation, the management of cases where the tubes have been coughed up, 
secondary stenosis from cicatrix, granulations, or oedema, the select on of special 





Fig. 72 



Fig. 73. 





Fig. 74. Fig. 75. 

Figs. 72-75. — Techxique of Ixtub.\tion (after Trumpp). 



tubes for oedema of the epiglottis and venti'^ular bands, retained tubes, etc. A 
new tube should be used for each case. If the operator is in doubt as to 
the proper size, the smaller size should be chosen. The tube may be dis- 
infected immediately before using, and a minute quantity of iodoform oint- 
ment may be used as a lubricant. When the tube is in the larynx, and not 
blocked by detached membranes, a characteristic moist rattle will be heard 
as the air is forced in and out in respiration. Before removing the gag, 
the left index finger is rapidly passed to the head of the tube to determine 
positively that the tube is in its proper place, then the string and finally 
the gag are removed. It is best not to use a string which is too strong to 
be broken, for in case it should become wedged in its eyelet, the string 
may be broken away with the index finger at the head of the tube to prevent 
dislodgement. If a detached membrane has been forced down, the child 
will become more cyanotic, whereupon the tube should be pulled out by 
its string and reintroduced after the detached membrane has been expelled 
by coughing. If a tube is coughed up after having been in the larynx a 
day or two, a reintroduction is not necessary until urgent symptoms 



186 



PEDIATRICS 



demand it, and if a child has great difficulty in swallowing food, the tube 
may, in exceptional cases, be taken out once a day for the purpose of proper 
feeding. 

Feeding. — Some children will swallow liquids without difficulty, others 
will swallow semisolids best, such as custard, scraped meat, ice cream, 
sponge cake soaked in milk, hard yolk of egg, farina with egg, somatose, 
matzoon, or ice. Most children will swallow well in the dorsal-horizontal 
posture. Forced feeding by means of a tube (gavage) may become 

necessary, the tube being in- 
troduced through the nose or 
mouth. (See Gavage.) 

Medication. — Stimulants, 
heart tonics, and antipyretics 
can be given with the food or 
subcutaneously or per rectum. 
Tubes may be removed after 
two, four, or six days. Anti- 
toxine has shortened this 
period very much. When it is 
noticed that a greenish muco- 
pus is coughed up through the 
tube, it is time to remove it. 
To avoid pressure necrosis, a 
tube should not remain longer 
than six days. A moderate 
secondary stenosis after the 
removal of a tube may be re- 
lieved by a few five-grain doses 
of antipyrine. 

How TO Remove the Tube. 
— Place the child in the posi- 
tion for intubation, as described 
above. Thrust the left index 
finger past the epiglottis, hook 
it up, and with the tip of the 
finger as a guide introduce the extractor tip into the tube lumen and get 
a firm hold on the tube by depressing the handle. The tube is raised 
sufficiently to get the tip of the index finger under its head, and by this 
combined manipulation the tube is lifted out of the larynx and out of 
the mouth. In introducing, stand before the patient; in extracting, sit 
before the patient. After removing a tube, it is desirable to be within 
easy call for some time, as some cases need re-intubation even after twelve 
to twenty-four hours. If re-intubation is not necessary within one hour, 
the operator may leave the patient, but be within easy call. 

Retained Intubation Tubes. — Apart from ordinary "prolonged tube 
cases," a stenosis which occasionally persists in intubation cases is usu- 
ally the result of traumatism, i. e., laceration during attempts at intuba- 
tion, and pressure necrosis from badly constructed tubes that have been 
too !ong in the larynx and become roughened by calcareous deposit. Cica- 




FiG. 76. — Intubation of the Larynx. 



INTUBATION AND TRACHEOTOMY 



187 



tricial stenosis or granulations will be found at the entrance of the larynx 
at the base of the epiglottis. Such cases require expert management, and 
each case will need its own treatment. Hard rubber tubes for long wear 
and built up tubes with extra large heads and large retaining swell are called 
for. Accessible granulations may be removed, and superficial granulations 
may be attacked by coating the tubes with gelatin and alum or tannin, 
as suggested by O'Dwyer. In some cases, but rarely, tracheotomy must 
be done, with subsequent local treatment and dilatation. Specially built 
up tubes are also used when swollen tissue overrides the head of the ordinary 
tubes in primary intubation. As a dernier resort resection of the constricted 
portion of the larynx or trachea has been performed. 

Secondary stenosis, after intubation, due to abductor paralysis, has been 
reported, but lacks confirmation. Secondary stenosis or persistent hoarse- 
ness with moderate stenosis may be due to ankylosis of the crico-aryta>noid 
articulation, which may follow any local inflammatory process. Vibratory 
massage would be applicable to such conditions. Antitoxine and intubation 
combined have given such brilliant results in croup that primary trache- 
otomy is now rarely performed in this country for diphtheritic stenosis. 
A rapid tracheotomy may become necessary if, in the act of tubing, the 
stenosis shoud suddenly become complete. This accident has happened 




Fig. 77. — Intubation Statistics of Bud.vpest Stephanie Children's Hospital. 

Serum period represented by thick line . Mortality represented by the interspace 

between two lines. (Prof. Bokay.) 



to the writer in tubing an adult for stenosis of several weeks' standing 
and of unknown origin. The tube struck a subglottic vascular new growth, 
which bled freely into the bronchi. A rapid tracheotomy was performed 
and the haemorrhage fortunately arrested, the patient making a complete 
recovery. Intubation in the adult is a difficult and rather unsatisfactory 
procedure. In diphtheria cases with great swelling of the tonsils, of the 
uvula, and at the entrance to the larynx, tracheotomy would probably be 
the most satisfactory operation. 

Tracheotomy is not a difficult operation, but is, as a rule, an unpleasant 
one in private practice. In performing the operation the surgeon is usually 
fortunate if one trustworthy assistant is at hand, who is expected to 



188 



PiEDIATRICS 



administer the anaesthetic and assist at the wound as well. Now, if the patient 
is in any way troublesome, as is frequently the case, the operator may not 
be able to proceed with the necessary ease and facility. In such a case 
the author's automatic retractor will be of service; it will keep the edges of 
the wound well apart, it may be hooked into the fascia as the several layers 
are divided, it will hold aside such blood vessels as are in the way of the knife, 
and may finally be hooked into the edges of the tracheal wound, the trachea 




Fig. 78. — Larynx of Child Two and a half Years Old. 

Showing ulceration caused by too large a tube. The ulceration at a involves the whole thick- 
ness of the cartilage. Those at b and c are mere abrasions. (Dr. M. Nicoll, Jr.) 



may be examined at lei ure, and there need be no haste in getting the tube 
into its place. • 

The instrument, devised many years ago, consists of a rubber band 
to each end of which is attached a curved double hook of nickel plated 
steel. It can be used as a general retractor in operations requiring careful 
dissection in different parts of the body; but it is especially applicable 
to the neck. 

The instrument can be disinfected and the rubber must be renewed 
occasionally. 

With a bottle, wrapped up in toweling to act as an appropriate support 
at the nape of the neck, and the child under chloroform, an incision is made 
about two inches long, from the superior border of the thyreoid cartilage 



INTUBATION AND TRACHEOTOMY 



189 




n I 

Fig. 79. — Built up 
Heat fou Granu- 



downward. The best guide is the cricoid ring, which is the most prominent 
part to be felt in children. After the skin has been incised, the superficial 
fascia is divided on a director, and the presenting 
veins are held aside by means of the author's re- 
tractor. To get at the three upper tracheal rings 
above the thyreoid isthmus, we make a transverse 
incision into the deep fascia where it is inserted into 
the cricoid cartilage (Boze's point). This done, the 
deep fascia, and with it the isthmus of the thyreoid 
gland, can be pushed downward with any blunt in- 
strument, and enough space gained to open the tra- 
chea. The trachea can also readily be reached below 
the isthmus of the gland by means of blunt prepara- 
tion and by the aid of the automatic retractor, little 
else but fat and dilated veins presenting themselves 
in this region. In opening the trachea we cut from 
below upward, and do not plunge the knife into the 
trachea with any force, so as to avoid injury to the 
posterior tracheal wall. After the membranes and 
secretions have been expelled by coughing, the tube lations. 
is introduced and secured by a tape around the neck. 

The tube is removed at least once a day and cleansed, and should not be 
discarded until the patient is able to breathe for days with the inner tube 

out and the outer tube closed 
with a cork. 

To cleanse the tracheotomy 
wound with the tube m situ, 
the writer attaches a rubber 
tube six inches long to the tra- 
cheotomy tube, and uses a 
strong spray of any desirable 
antiseptic solution; the attached 
rubber tube prevents the spray 
fluid from entering the trachea, 
and permits breathing at the 
same time. When there is 
much difficulty in expectorating 
the secretions, a few drops of 
salt water occasionally dropped 
into the trachea through the 
tube will facilitate their expul- 
sion. Feeding and medication 
present no difficulties. Sec- 
ondary granulations are excised 
or cauterized, and intubation may be done to discard a tracheotomy tube 
in difficult "decanulement." 




Fig. 80. 



-Author's Automatic Tracheal 
Retractor. 



190 



PAEDIATRICS 



Disinfection of the Sick Room. See also article on Disinfection 

The general principles involved in the prevention of infectious disease 
are not complex: 

1. Isolation of the patient, and avoidance of the sick room. 

2. Disinfection of rooms and their contents by steam or chemicals 
or by cleanliness and sunshine; personal disinfection and prophylaxis, 
including fortifying the system. 

3. Ventilation to prevent concentration of poisonous matter. 

The management of diphtheria and scarlet fever in a private house 
according to these principles is not difficult. The patient is isolated in a 
clean room, bare of all but the necessary furniture. A hall bedroom or one 




Fig. 81. — Cleansing Tr.vcheotomv Wi 



JIM) Willi 



TriiK IN Situ. (Author'.s nuih 



on the top floor is to be preferred. In some instances it may be advisable 
to keep the patient in the ordinary bedroom occupied at the time of being 
taken sick, and quarantine, in the best manner possible, this floor of the 
house already infected. The well children are to be kept from school and 
church. Where the intercourse of parents with a sick child cannot be 
avoided, even when trained nurses are employed, it may become necessary 
to isolate the well children. Food and drink not consumed by the patient 
must be burned or disinfected in a slop jar holding a chlorinated soda 
solution. Dishes should be rinsed in soda solution, 5 per cent, and a subli- 
mated solution 1 to 1,000, before returning them to the kitchen. As dried 
sputa are liable to be spread through the air, all expectorated matter 
should be received into rags or paper spittoons, which are to be burned, 



TONSILLITIS, PERITONSILLITIS, QUINSY 191 

or into a jar holding a sublimate solution, 1 to 1,000. The sick room 
should not be swept with a broom, to avoid raising dust. For cleaning 
purposes, employ moist rags, which are to be burned. Urinals, bed pans, 
and faces are treated with quicklime, bichloride solution, 1 to 1,000, or 
Labarraque's solution. 

The nurse should not eat or drink in the same room with the patient, 
and before going to meals she should clean her hands and arms with green 
soap and sublimate solution, 1 to 1,000, and put on a clean, long, loose 
gown, which hangs outside of the sick room. During the period of desqua- 
mation the patient should receive a daily bath of tepid water containing 
green soap. At the termination of a case the nurse takes a bichloride bath, 
1 to 2,000, and washes her hair with the same solution. In case of death, 
the body is to be wrapped up at once in a bed sheet soaked in mercuric 
bichloride solution, 1 to 1,000, and no public funeral is to be permitted. 
The sick room and all objects in it must be disinfected. Hard finish or 
painted walls and ceilings and floors may be washed or sprayed with dis- 
infecting fluids. Papered walls may be rubbed down with a damp cloth 
or bread crumbs; or, better still, the paper should be removed. A fresh 
coat of kalsomine or whitewash is advisable wherever it can be applied. 
After disinfection, the windows must be kept open day and night for several 
days. Carpets, upholstered furniture, and other articles can be disinfected 
by steam through the health board or at private disinfecting plants. 

Recently formalin vapor has been extensively used for disinfecting 
sick rooms and their contents, and, as far as my experience goes, I consider 
it to be a powerful disinfectant, far superior to sulphur. Formalin vapor 
is generated in an apparatus which permits the gas to be discharged by 
means of a tube through the keyhole into a room which is otherwise tightly 
closed. 

TONSILLITIS, PERITONSILLITIS; QUINSY 

The ordinary clinical variations of acute tonsillar inflammation are: 

1 . Follicular tonsillitis (non-diphtheritic) . 

2. Croupous tonsillitis ) j t i .i • 

n T71 7 ^ -iT^- } pseudodiphthena. 

3. U Icero-membranous tonsillitis ^ ^ ^ 

4. Diphtheritic tonsillitis. 

No amount of experience will enable us to distinguish clinically between 
1, 2, 3, and 4 in any locality in which diphtheria is endemic. What looks 
like tonsillitis to-day may be diphtheria to-morrow. Such cases must be 
isolated and treated like diphtheria; if a subsequent examination proves 
the contrary, no harm has been done. The so called pseudodiphtheria 
kills children as well as the Klebs-Loeffler variety. In this field the value 
of bacteriological examinations as practised in large cities has been over- 
estimated. In country districts in which diphtheria is not endemic and 
in immunized children in the city we see cases of undoubted acute fol- 
licular tonsillitis, but there are no reliable differential points. At the bed- 
side in acute sore throat cases, clinical observation goes before laboratory 
statistics, and a report " No diphtheria bacilli found " should influence 
the practitioner but very little, if at all, in the subsequent management 
of a case. 



192 PEDIATRICS 

Differential Points. — Syphilis, leptothrix, and other rare parasitic affec- 
tions of the tonsils; are not liable to be confounded with diphtheria, 
pseudodiphtheria, or tonsillitis. Membranous and ulcerative lesions of 
the mouth and throat may be due to the spirillum of Vincent (diphtheroid 
angina). Such deposits gradually disappear after mild local antiseptic 
treatment. 

Symptoms. — The symptoms of tonsillitis are fever, general malaise, 
vomiting, pain on swallowing, and noisy respiration. The tonsil is red and 
swollen; the lymph nodes are swollen; the tongue is coated. In follicular 
tonsillitis a punctate, cheesy deposit protrudes from the crypts of the tonsil. 

Treatment. — A child afflicted with so called tonsillitis should be isolated 
and should receive a warm bath and a laxative or an enema, and should be 
put to bed. A cool compress may be placed around the neck, and over this 
a flannel bandage. The compress may be renewed every hour or two, or 
an ice poultice may be put around the throat (ice and sawdust wrapped in 
oiled silk). 

The child should receive cooling drinks and a liquid diet. (See Fever 
Diet.) Salt water should be dropped into each nostril every two to three 
hours. (See Nasopharyngeal Toilet.) 

Internally the following prescription may be administered: 

I^ Tinct. iodini, gtt. x; 

Aquae menth. pip., 5jss.; 

Syr. simplicis, 5ss. 

M. Sig. : A teaspoonful every hour. 

Older children may have cracked ice to swallow, and gargle with chlorate 
of potassium solution (2 per cent). The prognosis is favorable. 

It must be emphasized, however, that in all centres of population in 
which diphtheria is endemic even a simple tonsillitis must be looked upon 
with suspicion, and at the first sign of a cheesy or membranous deposit, 
be it punctate or not, a curative dose of diphtheria antitoxine (2,000 to 
4,000 units) should be administered to children in order to be on the safe 
side as regards further development. 

Phlegmonous Tonsillitis, or Quinsy. — The jaws become stiff, and the 
mouth is opened with difficulty. Swallowing is very difficult; food re- 
gurgitates through the nose; the voice has a nasal character; fever and 
constitutional disturbances are marked; and there may be hoarseness or 
noisy respiration. . 

Treatment. — Is the same as in the mild variety. Children should re- 
ceive 2,000 units of antitoxine. If cold applications are not tolerated, a 
hot poultioe or hot water bag may be applied. Early incision of a pointing 
abscess or fluctuating soft area, with or without local anaesthesia, is of the 
utmost importance on account of the danger of oedema of the glottis and 
death from suffocation. Surgical interference from without through the 
skin is often necessary under general anaesthesia, in order to relieve tension 
when deep tissues are involved. In the severe and dangerous form known 
as angina Ludovici the tissues of the neck present tense induration, and a 
fatal termination is the rule unless good and timely surgical interference is 
at hand. 



HYPERTROPHIC TONSILS IN CHILDREN 



193 



HYPERTROPHIC TONSILS IN CHILDREN 

Enlarged tonsils obstruct the posterior nares and are a prolific source 
of nasal and aural disease. They are frequently found associated with 
adenoid vegetations in the vault of the pharynx. 

Symptoms. — Nasal voice, reflex cough, noisy respiration, peculiar facial 
expression, mouth breathing, snoring at night, deafness, and restlessness in 
sleep. 

Enlarged tonsils are usually the product of repeated attacks of tonsillitis, 
and have in themselves a tendency to acute inflammation. Inflamed tonsils 
are a source of 
danger to the in- 
dividual, as they 
appear to favor 
systemic septic in- 
fection, with subsequent localization in vital organs 
(endocarditis and myocarditis). As a portal of entrance 
for infection, however, the inflamed or enlarged tonsil is 
of minor importance as compared with the retropharynx 
in a state of inflammation or irritation. 

Treatment. — The reduction of enlarged tonsils in 
children is best accomplished by means of the tonsillo- 
tome, at one sitting. The use of the tonsil knife and 
cutting forceps for the purpose of slitting up the crypts 
and removing tissue piecemeal is more adapted for work 
upon adults. The Tiemann-Fahnenstock or MacKenzie 
tonsillotome, is perhaps the handiest instrument to use 
in connection with the intubation gag. The tonsillo- 
tome will remove a tonsil which can be engaged in its 
ring. Tonsils which are fixed by adhesion to the an- 
terior pillar of the soft palate cannot as a rule be en- 
gaged by the tonsillotome blade until the adhesions 
have been loosened so that the tonsil may protrude, 
trophic tonsils extending low down in the pharynx also present diffi- 
culties in the way of removal. The tonsillotome may have to be applied 
twice to the same side. In many instances the removal of the upper, 
greater portion of the tonsil will relieve the symptoms on account of which 
the operation was done. Soft, friable tonsils are apt to be crushed by a 
blunt ring knife and may require subsequent trimming with curved blunt 
pointed scissors. Anaesthesia in tonsillotomy is not absolutely necessary. 
If the parents of children request an operation under anaesthesia, ether is 
perhaps the safest anaesthetic, all things considered, and the narcosis need 
not be deep. The tonsillotome should be sterilized by boiling in a weak 
soda solution, and if there is time the nasopharyngeal toilet should be em- 
ployed for a few days prior to the operation. If one is compelled to operate 
during an epidemic of diphtheria, a prophylactic dose of antitoxine is in 
order. 

After-treatment and Sequelae. — After the tonsils are out, the parent is 
told that the child may vomit dark blood which it has swallowed, and that 
14 



Fig. 82. — McKenzie 
Tonsillotome. 

Elongated hyper- 



194 



PEDIATRICS 



a fresh haemorrhage should be reported at once. The patient must have only 
soft or liquid food for a few days, and the nasopharyngeal toilet should be 
practised. Older children will gargle in addition. 

The formation of a pseudomembrane on the wound made by the ton- 
sillotome is frequently observed, with and without constitutional symptoms 




Fig. 83. — Tiemann-Fahnenstock Tonsillotomb. 

(fever). This may be due to an unclean instrument, an unclean throat, 
or both. 

Dangerous haemorrhage after tonsillotomy is rare in children unless 
they have the so called haemorrhagic diathesis. Bleeding may be controlled 
by ice or alum solution (both should be at hand), and digital pressure with 
the thumb can be kept up for hours if necessary. If bleeding cannot be 
controlled by such means or by the actual cautery, the external carotid 
will have to be ligated. 

It is best, all things considered, not to remove the tonsil completely, 
but to leave a small stump which could be grasped by a forceps for the pur- 
pose of controlling severe haemorrhage. The teaching that a tonsillotomy 



^ 



Fig. 84. — Tonsil Knife (Douglas). 

is a failure unless the tonsil is completely removed is not in harmony with 
the experience of the writer. Tonsils and adenoids can be removed at one 
sitting under ether anaesthesia. 



ADENOID GROWTHS AND THEIR REMOVAL 

Adenoid vegetations are common in children and give rise to excessive 
discharge of mucopus, with reflex cough. The character of the voice is 
altered, and mouth breathing is the rule. The presence of adenoids often 



ADENOID GROWTHS AND THEIR REMOVAL 



195 



causes ear symptoms (pain and chronic otitis) , and bed wetting is frequently 
observed in children with nasal obstruction. A positive diagnosis is readily 
made by a digital exploration with the index finger, nail side up. The 




Fig. 85. — Beckmann's Curette for Adenoids. , 

growths are of a soft, pulpy consistence — in some cases the growths are firm 
and feel like a bunch of worms. 

Local medication will not effect a radical cure, which can only be ac- 
complished by extirpation of the growths. The operation can be performed 
without an anaesthetic or under ether narcosis. The patient is firmly held 




Fig. 86. — Post Nasal Fenestrated Forceps for Adenoids. 



in an upright position and the mouth held open by mouth gag (intubation 
gag). A properly curved fenestrated post nasal forceps is inserted behind 
the soft palate into the vault of the pharynx; the branches of the instrument 
are opened and then closed, whereupon the instrument is removed, carrying 
with it as much of the growth as has been caught within its branches. 
A Beckmann curette is now inserted in the same way, and by dexterous 





Fig. 87.- 



-Adenoids Before Operation. 
(Dr. French.) 



Fig. 88. — Adenoids After Operation. 
(Di. French.) 



manipulation the remaining adenoids are planed off. The removal of a 
portion of the growth wath forceps is mainly for the purpose of demon- 
strating to the parents of children the nature of the trouble. The brisk 



196 



PAEDIATRICS 




haemorrhage following the operation usually stops promptly, or alum water 
may be dropped into the nostrils as a styptic. If performed under an anaes- 
thetic, the position of the head must be such as to avoid asphyxia from 
flow of blood into the trachea. 

Removal of Adenoids and Tonsils under Ether. — Chloroform as an an- 
aesthetic appears extra hazardous to those having a lymphoid tendency. 
After the child is anaesthetized (the head being de- 
pendent over the edge of the table and supported 
by the assistant), the jaws are held open with a mouth 
gag, the forceps is introduced, and all tissue within 
its grasp is removed. Then the curette is used, and 
the finger may sweep all over the postnasal space to 
detach loose tissue with the nail. The patient is 
turned over on his face and the blood allowed to 
flow out, the nose and throat are well sprayed with 
an iced antiseptic solution, and the operation is fin- 
ished. The patient is now placed in bed, the direc- 
tions are given for a soft diet, and a spray of the iced 
antiseptic solution in the nose and throat is used 
once every two hours. On the following day the 
patient may be up and about. In operating for phi- 
mosis, adenoids and enlarged tonsils if present can be 
removed before the pa- 
tient is out of his nar- 
cosis, and vice versa. 

In severe hcemorrhage 
following the operation 
a tampon saturated with 
alum water may be 
firmly wedged into the nasopharynx, as in 
nasal haemorrhage. 

Possible and Avoidable Traumatism 
During Operations for Adenoids. — Trau- 
matism of the soft palate; injury to the pos- 
terior border of the septum; injury to the 
pharyngeal wall in extreme curvature of the 
cervical vertehrce. 

Morbid Conditions Simulating Adenoids to 
Account for the Persistence of Symptoms after 
the Removal of Adenoids and Large Tonsils. — 
Many children with symptoms pointing to the 
existence of adenoids are found upon exami- 
nation to be suffering from some other affec- 
tion. The conditions which have been found 
to simulate adenoids comprise the following: 

1. Diminutive choance and nostrils. These occur frequently and in 
association with a low vault of the pharynx and other anomalies of develop- 
ment in subnormal children. These defects appear to be of rhachitic origin 
in some cases. 




Fig. 89. — Adenoids Be- 
fore Oper.\tion. 
(Dr. French.) 




Fig. 90. — Adenoids After 
Operation. (Dr. French.) 



RETROPHARYNGEAL LYMPHADENITIS AND AfiSCESS 197 

2. Paresis of the soft palate and pharynx. This affection is sympto- 
matic of a number of conditions. 

3. Septal anomalies. The septum may be prolonged backward into 
the nasopharynx, dividing the latter into two compartments. 

4. Forward projection of the vertebral column, usually due to deformity 
of the arch of the atlas. 

5. Retropharyngeal abscess and the enlarged lymph ganglia from which 
the former originates. 

6. Undue prominence of the soft parts over the internal pterygoid plate. 

7. Ordinary neoplasms of the nasopharynx. 

RETROPHARYNGEAL LYMPHADENITIS AND ABSCESS 

The vast majority of cases in children arise from suppuration of the 
lymph nodes, and not from caries of the spine. Infection of pharyngeal 
lymph nodes takes place from the mucous lining of the nasopharynx. It 
may be tuberculous, but generally it is simply inflammatory. The writer 
has known it to develop in children whose pharynx had been repeatedly 
examined with the fingers by medical students. 

Symptoms and Diagnosis. — Young children, when brought to the phy- 
sician suffering from an incipient retropharyngeal abscess, are restless and 
refuse food. They have a nasal cry, " voix de canard," and at first no definite 
localization of the fever or its cause is possible. Gradually the throat 
symptoms increase; the breathing becomes noisy and dyspnoea is urgent, 
particularly in cases in which the abscess is low down, and swallowing 
is difficult and painful and accompanied by regurgitation. The head is 
held in a characteristic position and turned to one side. On examining the 
throat by reflected light or sunlight, we find it in a swollen condition, and 
in the majority of cases we notice a bulging of the posterior pharyngeal 
wall. Careful digital examination will tell us more definitely the extent 
and location of the soft fluctuating tumefaction. In rare instances a sudden 
attack of dyspnoea is the first symptom noticed. 

Differential Diagnosis. — A diphtheritic pseudomembrane is absent 
and there are no hoarseness and aphonia, as in croup. Adenoids and en- 
larged tonsils will give almost identical symptoms and may also be present 
as a complicating feature. The educated finger will recognize the actual 
condition with which we have to deal. 

Treatment. — A localized accessible abscess may be opened by direct 
incision through the mouth. A thin walled abscess may be punctured by 
means of a blunt dressing forceps, and the branches of the forceps may be 
spread to encourage free exit of the pus. The child's head must be lowered 
to prevent flooding of the larynx. A retropharyngeal abscess opened by 
a simple small incision is apt to close and fill again, but an opening made 
by a blunt instrument does not heal up. In operating from the mouth 
narcosis is usually not feasible. 

In the presence of marked dyspnoea and a deep seated abscess low down 
and difficult to reach, and in those cases in which the pus has spread down- 
ward toward the lateral surface of the neck, a direct incision from outside 
behind or in front of the sternocleidomastoid muscle and under antiseptic 



198 ■ PAEDIATRICS 

Drecautions is indicated. In weak babies under one year opening the ab- 
scess through the mouth is to be preferred, on account of the danger 
associated with general anaesthesia. Tracheotomy is rarely called for, as 
it usually takes a week before suffocation becomes imminent. Intuba- 
tion is not applicable in such cases, as the swelling would override the end 
of the tube. 

Prognosis. — In cases of retropharyngeal abscess in children the prog- 
nosis depends upon the age of the patient and the time and manner of 
treatment. Death may occur slowly from asphyxia or suddenly, in ad- 
vanced cases, from suffocation, due to rupture of the pus sack. Pus may 
burrow in various directions or discharge through the ear. A timely 
incision will save almost all the patients. 

Nasal intubation by means of soft rubber tubes is sometimes applicable 
in cases of dyspnoea due to acute nasopharyngeal swelling in infants. 



ERUPTIVE AND OTHER FEVERS 

MEASLES ; MORBILLI 

Introductory Remarks. — An acute infectious and highly contagious dis- 
ease, the specific microorganism of which has not been isolated, character- 
ized by a prodromal stage with coryza, fever, cough, "dull eyes " or pink 
eyes, followed by a brownish red macular and papular eruption. The 
period of incubation is not definitely known, but is supposed to be from 
seven to eleven days. If sixteen days elapse after exposure without the 
disease developing, the person may be considered safe from an attack. 

The exanthem appears about the fourth day, first on the face, which 
has a mottled and swollen appearance, and spreads over the trunk and 
entire body. It is also visible on the mucous surfaces of the mouth and 
throat. The skin eruption lasts until the sixth or seventh day, and then 
gradually fades. A desquamation occasionally sets in in the form of very 
minute scales. 

Peculiarities of the Preeruptive Stage in Measles. — As a fore- 
runner of the rash, small red spots, "Koplik spots," with a minute blue white 
centre, have been described by Flindt, Reubold, Flatow, Hilton, Fagge, 
Koplik, and others as occurring on the inner surface of the cheeks in many, 
but in not all cases. Dr. M. Flindt, in the records of the Danish Sundheds 
Collegium, 1880, describes these spots as follows: "Second day of fever: A 
spotted erythema may be seen on the mucous membrane of the cheeks 
and lips. This shows quite a remarkable appearance, due to the numerous 
minute bluish white, shining, and apparently vesicular points which lie 
in the centre of small red spots and are arranged in irregular groups. One 
can feel as well as see the small vesicles projecting above their surroundings. 
Third day of fever: Similarly grouped spots with vesicles are visible on 
the buccal mucous membrane, especially on the part of it lying opposite 
to the space between the upper and lower back teeth. At this stage the 
skin eruption first makes its appearance." Dr. Koplik, of New York, de- 
scribes these spots in the Medical Record of 1898 (No. 1431), and distinctly 



MEASLES 



199 



points out that they are often present from twelve hours to five days 
before the cutaneous eruption, and that their presence may enable us to 
isolate our cases earlier than formerly and aid us in distinguishing measles 
from other skin eruptions. 

Another peculiarity of measles infection, according to the experience 
of the writer, is that the temperature curve in the -preeruption stage may show 
a remission to normal or subnormal at irregular periods on the febrile days 
preceding the eruption, as shown in the chart. The knowledge of these 
points is important as regards the early recognition of the disease and the 
isolation of the patient. (Trans, of the Amer. Peed. Soc, June, 1898.) 

Prognosis. — Uncomplicated cases end in recovery. In the form known 
as haemorrhagic, or black, measles death often results from an overwhelming 




Fig. 91. — Temperature Curve in Measles. 



toxsemia. In adults measles is usually of a severe type; in infants and 
delicate children it is often fatal. 

Differential Diagnosis. — In rubella the rash appears earlier, it is 
evenly distributed and not blotchy, and all the symptoms are mild. Scarlet 
fever has a sudden onset and no preemptive remission. The throat is 
sore and the rash is scarlet; the eyes are bright. 

Prevention. — One attack usually confers immunity. It is so highly 
contagious that it is extremely difficult to keep it out of children's hospitals 
and wards. Plastic operations should not be attempted on children who 
have not had measles and who have recently been exposed, on account of 
serious interference with the healing process in the event of their being 
attacked with measles. 



200 PiEDIATRICS 

Treatment. — We have no specific medication for measles. The patient 
is given a warm bath and an enema or laxative, and kept in bed, isolated, 
for a week. The room should be well ventilated and not heated above 
68° F. The patient should have a fever diet and cooling drinks. Very 
high fever is managed by hydrotherapeutics (see General Therapeutics). 
The nasopharynx is to be kept moist and clean by dropping salt water 
from a spoon or pipette into each nostril four times a day. This will also 
ameliorate the throat cough. A warm bath may be given daily, and the 
eyes may be frequently washed with boric acid solution. In extreme 
restlessness a single dose of antipyrine or phenacetine may be given at 
night. When the cough is very annoying, from 5 to 10 drops of paregoric 
may be given occasionally. 

Complications and Clinical Varieties. — Incessant hacking cough; croupy 
cough; aphonia and stenosis of the larynx; active angina; follicular ton- 
sillitis; visible diphtheria and croup; nasal diphtheria early or late (often 
overlooked); late membranous croup; pertussis; bronchopneumonia and 
lobar pneumonia or tuberculosis of the lung; severe conjunctivitis; sto- 
matitis and gastroenteritis; gangrene in the mouth; gangrene elsewhere; 
otitis media. 

If there is the slightest indication of a membrane in the throat or nose, 
or progressive hoarseness with stenosis, full and repeated doses of diphtheria 
antitoxine should be given (see Diphtheria and Croup). When a nasal 
discharge persists after the measly eruption has disappeared, and particularly 
if the discharge is bloody or offensive, a culture should be made arid search 
undertaken for the Klebs-Loeffler bacillus. If hoarseness and aphonia 
develop, with a nasal discharge, after measles, antitoxine is indicated at 
once, even if the throat is clean. 

The various other complications of measles are discussed under the 
various headings. In rare instances hoarseness and a mild degree of 
stridulous breathing may persist for a long time following measles. This 
complication, which may be termed a chronic laryngitis, is not improved 
or cured by medication. In such a case the child should be sent to the 
country or to the seashore, away from a dust laden atmosphere. The 
administration of potassium iodide by the mouth or rectum, gr. 11 to 5 
three times a day, is rational whenever syphilis is suspected as an under- 
lying cause of such hoarseness. 



RUBELLA ; ROTHELN ; GERMAN MEASLES 

This infection is seen in two types, one resembling mild measles and the 
other resembling mild scarlatina. The rash comes out in pinkish spots 
(maculo-papules) on the first or second day. It appears first on the face 
and spreads over the whole body. It persists from three to five days, 
and may be followed by a slightly perceptible desquamation. The tem- 
perature is seldom more than 100° or 102°. In the absence of a bacterio- 
logical test it cannot, except in theory, be distinguished from mild measles. 
It is contagious, and there is swelling of the posterior cervical glands. It 
occurs in epidemics, it is distinct from measles and scarlet fever, and it 



SCARLET FEVER 201 

may be confounded with measles, scarlatina, influenza, and erythema 
multiforme. Complications and sequelae are seldom observed. 

The treatment is by isolation and rest in bed for a week, liquid diet, 
fresh air, and attention to the bowels. 

VARICELLA (CHICKENPOX) 

A papular eruption ushered in with slight fever and malaise and occa- 
sionally a temperature of 103°. The eruption becomes vesicular in a short 
time, and the vesicles are frequently surrounded by a narrow area, or circle, 
of hyperajmia. The vesicles may hold a clear or cloudy fluid and may 
become umhilicated. In drying up they form a crust which drops off without, 
as a rule, leaving a scar. The vesicles may appear in successive groups. 
The contagium of the disease has not as yet been isolated, and it is at times 
very difficult to discriminate between varicella and varioloid. Chickenpox 
is not rare in adults. 

The S3maptoms are those of a mild infection, with general malaise and 
slight fever before the eruption. In discriminating between varioloid 
and varicella we should be guided by the following points: In varicella 
the eruption usually appears first upon the trunk, rarely on the forehead 
or face. The vesicles vary in size, break readily, and are superficial with 
a very slightly marked red areola. They develop in successive crops. 
All stages can be seen side by side. There is usually a history of exposure 
to varicella. The constitutional symptoms are mild. In variola there is a 
more sharply defined hyperaemic area surrounding the variola vesicle. In 
the early stage of its eruption the forming vesicle feels like " shot " under- 
neath the skin. In smallpox the hands and feet usually show hard and 
circumscribed papules. Varicella and scarlet fever may occur together. 
In rare instances the skin becomes infected through a broken vesicle, or 
pock, and erysipelas or gangrene of a patch of tissue may result. Un- 
complicated cases of chickenpox get well. 

Treatment. — Direct quarantine in a well ventilated, sunny room, order 
soft diet, and open the bowels. The eruption in the mouth requires a 
mouth wash of chlorate of potassium (2 per cent solution). For varicella 
of the vulva we apply cold cream. 

SCARLET FEVER 

Introductory Remarks. — Scarlet fever is an infectious disease the specific 
poison of which, highly contagious and capable of reproducing itself, has 
not as yet been isolated. It probably enters the system through the naso- 
pharynx and respiratory tract, and may be conveyed in all the ways in 
which contagious disease is distributed. The main factor in the causation 
of epidemics is personal intercourse. It is believed, but not proved, that 
domestic animals may contract scarlet fever transmissible to man. Milk 
epidemics and drinking water epidemics, as reported in literature, lack 
bacteriological proof. The common mode of infection is by direct or inter- 
mediate contact with a scarlatinous patient, and by contact with the secre- 
tions, excretions, and exhalations of the body, and by means of books, toys, 



202 PEDIATRICS 

etc., soiled by patients having scarlet fever. The period at which scarlet 
fever is most contagious and the duration of capacity for infection are not 
definitely known. The susceptibility and immunity of individuals and 
families, and the period of incubation, are inconstant; the latter varies 
from a few hours to a few weeks. No age, sex, or race is exempt. Few 
cases, however, occur in adults. Ill ventilated and filthy localities are 
favorable for the propagation of scarlet fever. Most cases occur during 
the cold season of the year, when the closing of windows prevents proper 
renewal of air in the houses. 

The severest forms are observed in children of a lymphatic diathesis 
whose nasopharynx is not normal (croupy children). On the other hand, 
scarlet fever complicated with diphtheria may run a comparatively safe 
course in children afflicted with adenoids and enlarged tonsils and generally 
of anaemic appearance. This would naturally lead to the inference that the 
contagion had various degrees of virulence, and that the blood offered 
more resistance to the infection in one case than in another. Regarding 
this important question we are still in the dark. 

The mortality may be as low as 5 per cent in some epidemics, and as 
high as from 30 to 40 per cent in others. According to the reports of the 
New York State Board of Health, scarlet fever is most prevalent in the 
first four months of the year. 

Infection ceases with the termination of desquamation and convalescence. 
The failure to establish the origin of sporadic cases is due to defective 
methods of investigation in the absence of positive knowledge as to the 
exact nature of the poison. 

Scarlet fever is very prevalent and has a large mortality and many 
and dangerous sequelae; thus the wisdom and necessity of preventive measures 
are self-evident. The poison of scarlet fever may be diluted and rendered 
innocuous by persistent ventilation and disinfection; this, together with 
isolation of the patient, limits the spread of infectious disease in a household, 
institution, or community. The fact that some contagious diseases are 
infective during the preeruptive stage is no argument against the necessity 
of taking active preventive measures for the three or four weeks following, 
during which time infection still continues. At least three weeks should 
elapse from the date of exposure before freedom from danger of an attack 
is secured. 

The period of incubation is supposed to vary from one to seven days. 
A child exposed to scarlet fever contagium and remaining free for two 
weeks may be considered out of danger. The utmost care should be ex- 
ercised to keep scarlet fever out of lying-in and operating rooms. 

Mother and infant may have scarlet fever after childbirth, and in many 
instances the results of plastic operations are marred by flaps sloughing 
from scarlatinal disease following operation. 

After the discovery and isolation of the specific poison of scarlet fever, 
which is not unlikely to take place in the near future, we may also hope to 
obtain specific means to immunize and cure. Under all circumstances it 
is the duty of the general practitioner to inform himself as regards the best 
methods of prevention and disinfection, and to urge their adoption in every 
case coming under his notice and care. These methods of prevention are 



SCARLET FEVER 203 

applicable to all infectious diseases and are discussed in a special chapter 
on Infective Fevers. 

Onset and S)anptoms. — The disease begins abruptly as a rule with 
vomiting and thirst, rarely with a chill; young children may have convul- 
sions. The fever rises to 104° or 105°, the pulse is rapid (120-150), the 
respiration is increased in frequency, and the child complains of sore throat. 
The scarlet rash appears on the second day, on the neck and chest 
first, and may spread over the entire body within the next twenty-four 
hours. The rash is punctate or finely papular, diffuse or in patches, and 
slowly disappears after persisting from two to five days. The throat looks 
red and swollen, and the tonsils may be covered with a punctate exudate. 
Pseudomembranes and diphtheritic patches are often seen on the tonsils 
and pharynx. From the gross appearance of these patches one is unable 
to say whether they are Klebs-Loeffler or streptococci patches. As a rule 
they are of a mixed nature. Minute macules of a dark red color are gener- 
ally seen on the hard or soft palate. The lymphatic glands of the neck 
are swollen. The tongue is at first covered with a fur, and after a few days 
exfoliates and becomes red ("strawberry tongue "). Headache, general 
restlessness, insomnia, and delirium are present in severe cases. The urine 
is scanty and may contain albumin and hyaline casts. In favorable cases 
the temperature becomes normal on the seventh or eighth day, and desqua- 
mation sets in, lasting three weeks on an average and occasionally from 
six to eight weeks. 

Differential Diagnosis. — In the absence of a bacteriological test, it 
may be difficult and often impossible (except by those who can see the 
grass grow) to distinguish a scarlet fever rash from a scarlatiniform rash, 
such as we occasionally observe after the administration of certain drugs: 
Belladonna, quinine, antipyrine, iodoform, balsam of copaiba, etc., and also 
in cases of intestinal indigestion. Slight desquamation may even take place 
in a skin which has been the seat of a scarlatiniform rash, and desquamation 
following measles is nothing rare. 

The measles rash is of a brown red color, and presents itself in large 
irregular spots. The patient has coryza, cough, sneezing, and dull eyes. 
In German measles the throat symptoms are absent. 

Diphtheria with a scarlatiniform eruption cannot be distinguished 
clinically from a scarlet fever infection with diphtheritic sore throat; and 
as regards the drug and indigestion rashes, each case must be judged upon 
its merits. With a clear throat and normal temperature, it would seem 
unnecessary to quarantine a patient who happens to have a suspicious 
rash. 

Prognosis is uncertain. The mortality varies from 5 to 30 per cent. 
We have no means of gauging the power of resistance of the individual 
as regards sepsis, and, even when the acute stage is safely passed, subsequent 
complications may endanger and destroy life. Severe throat symptoms, 
early delirium, uncontrollable vomiting, high temperature, and high pulse 
are unfavorable symptoms. This is a brief pen picture of a moderately 
severe case of scarlet fever terminating favorably in due time. Apart from 
this form, we observie every variety as regards severity, complications, and 
sequelae. 



204 PAEDIATRICS 

The mild form may present itself with the rash, a red throat, and a 
temperature of from 100° to 101°, or the rash without throat symptoms 
and without fever. In this form the pulse is from 100 to 120. 

The severe form may present an initial diphtheria which spreads over 
the nasopharynx, with extensive pseudomembranous inflammation and 
much glandular swelling, invasion of the middle ear, and evidence of scar- 
latina on the second day. 

Malignant Form. — Initial throat symptoms with a yellowish greenish de- 
posit on the tonsils and throat, a scarlet rash on the second day coming 
out sparingly, a pultaceous condition of the throat, vomiting incessant, 
temperature high, pulse 150 to 180, active delirium, and death on the 
third, fourth, or fifth day. 

The ordinary onset with diphtheritic complications at the end of the first 
or second week. Heart, lungs, and kidneys free. 

Hcemorrhagic Form. — A black eruption, petechial or in large ecchymoses, 
with haematuria and other evidence of intense sepsis usually fatal from 
the second to the third day. Some patients recover. 

Fatal Septic Form. — Onset sudden and intense, temperature 106° to 
107°, delirium, vomiting, convulsions, coma, and death before the rash 
has had time to develop. 

Scarlatina and measles may coexist in the same person. Wounds 
predispose to the development of scarlatina (surgical scarlet fever). 

Treatment. — In very mild cases the children are to be put to bed on fever 
diet, and they require no other treatment. As soon as a child is known to 
be ill (with vomiting, fever, and sore throat), it should receive a warm bath, 
of 100°, and an enema, and be put to bed and isolated in a room the tem- 
perature of which is not over 65° to 68°. Should an inspection of the throat 
reveal a patch of pseudomembrane or a puslike exudate, 2,000 diphtheria 
antitoxine units should be injected at once and a swab culture taken. 
If diphtheria bacilli are reported found, the antitoxine injection should be 
repeated on the following day, and as often thereafter as may be necessary 
to check a complicating diphtheria. Diphtheria sepsis is not so readily 
checked by antitoxine in scarlet fever cases as in the uncomplicated variety, 
but in the experience of the author it does no harm and is the only rational 
specific treatment which we possess. The antitoxine may be administered 
daily or every other day, according to the indications, in precisely the same 
manner as in primary diphtheria without scarlatina. 

So long as there is much vomiting, ice to suck and cold and hot drinks 
are indicated. A fever diet is indicated. A strict milk diet is not of special 
import, but as milk is a perfect food in itself, it may be given to a patient 
exclusively if he will take it and tolerate it. Water should be given in 
considerable quantities to assist in elimination. When the vomiting has 
stopped, a good dose of calomel should be given, followed by a saline, to 
clear the bowels. 

A complicating diphtheria requires the nasopharyngeal toilet in addition 
to the antitoxine; and a cold compress may be put around the neck. Gar- 
gling with antiseptic solutions used in nasal irrigation is indicated for 
older children. 

Stimulation is indicated at any stage of the disease if the pulse is weak. 



SEVERE SYMPTOMS IN SCARLET FEVER . 205 

The treatment of scarlet fever by means of scarlet streptococcus serum is in 
the experimental stage. 

For nervous symptoms use the ice cap, baths, one or two doses of phena- 
cetine, or citrophen, gr. ij to v. 

Otitis media with perforation of the drumhead is a frequent compHca- 
tion. Occasionally complete deafness persists for a time, but eventually 
the hearing is reestablished in most cases. The indications for perforating 
the drumhead are discussed elsewhere (see Otic Memoranda). A discharg- 
ing ear is best managed by gentle irrigations with 2 per cent boric acid 
solution every three hours. To allay pain, a lukewarm boric acid solution 
holding 2 grains of cocaine to the ounce may be dropped into the ear 
from a spoon. Inflation of the ear by means of the Politzer bag or catheter 
should not be practised, on account of the danger of forcing septic material 
from the nasopharynx into the middle ear. 

Croup and stenosis of the larynx are managed according to the rules 
laid down in the chapter on Croup. 

Bronchitis may call for the administration of an expectorant, such as 
the aromatic spirit of ammonia. 

Painful and swollen joints are no unusual manifestations in scarlet 
fever and call for the administration of sodium salicylate and frequent cold 
compresses with the limb in a comfortable position. Torticollis following 
scarlet fever is occasionally observed. Swollen lymph nodes can be felt 
underneath the muscles of the neck in such cases. Mild massage is the 
proper treatment. If vomiting persists, a drop of tincture of iodine in a 
teaspoonful of sweetened water or peppermint water may be given every 
two or three hours. 

Treatment for Severe Symptoms, Complications, and Sequels. — 
Hyperpyrexia is best treated by warm baths and a single dose of an anti- 
pyretic, according to the rule laid down in the article on Pneumonia. 

In severe sepsis (rapid heart, delirium, high temperature) the patient 
may be kept in the warm bath for an hour at a time. The bath tub must 
be covered with a blanket in such a manner that only the head of the patient 
is exposed, and the bath room must be warm (75° to 80°). Stimulants 
may be given to the patient when he is in the water. After the vomiting 
is checked and the tongue remains coated, it is wise to give a few drops 
of dilute hydrochloric acid in sugar water three times aday, to aid digestion. 
Regarding the management of meningitis as a complication of scarlatina, 
the reader is referred to the article on Meningitis. 

Local Treatment op the Nose and Throat.— -In the mild as well as 
in the severe anginas the nasopharyngeal toilet is indicated. Swabbing or 
cauterization is not indicated. In the diphtheritic variety, in which anti- 
toxine is indicated, as already mentioned, it often happens that the swelling 
in the nasopharynx is so intense that swallowing is difficult, and a foul 
discharge and odor are noticeable from the nostrils. Such cases should have 
regular energetic irrigation of the nostrils in accordance with the rule in 
the article on Nasopharyngeal Diphtheria. 

When external sloughing is observed, a moist dressing of camphor 
water or balsam of Peru is probably the best. An extension of the diph- 
theritic process into the larynx, with stenosis, requires intubation. 



206 . PAEDIATRICS 

Itching of the skin may be allayed by sponging with 1 per cent carbolic 
acid water, or soda in water, or the free use of starch powder. 

Prolonged fever lasting for several weeks which cannot be localized is 
occasionally observed in otherwise uncomplicated scarlatina. It may be 
due to infection and swelling of deep seated glands and to other causes, 
and requires no special medication. Opening the bowels, warm baths, the 
breathing of good, cool air, and good feeding, with hydrochloric acid to 
aid digestion, constitute the proper treatment in such cases. 

Nephritis and dropsy in the wake of scarlatina are nothing unusual. 
The urine may contain blood or albumin and all sorts of casts. In this 
condition children may subsist on milk if they will take it. Warm tub 
baths and hot air baths in bed, under cover, may be employed, and an 
occasional dose of calomel or some other laxative is always in order. In 
urgent cases we may give an infusion of digitalis ( 5ss to 5iij), a teaspoonful 
every three hours. This increases diuresis by increasing the blood pres- 
sure. Or we can give one twelfth of a grain of pilocarpine once or twice 
a day as a diaphoretic and eliminant. In complete suppression of the 
urine life has been saved by cutting down upon the kidneys and split- 
ting the capsule of the congested and inflamed organ, thereby relieving 
its tension. 

Exfoliating dermatitis is occasionally observed as a complication of 
scarlatina. The entire skin is eczematous and moist, and a rise of tempera- 
ture accompanies the inflammation of the cutis. Desquamation then sets 
in and terminates in uninterrupted convalescence; or a renewed attack of 
dermatitis ensues, and death may finally result from exhaustion. Here, 
as in most other complications, the treatment is eliminative. The eczema- 
tous skin may be covered with cloths moistened with a weak lead lotion or 
soaked in Carron oil (linseed oil and lime water), or with ichthyol vaseline 
(1 per cent). The ordinary non-inflammatory desquamation is managed 
by a daily bath and vaseline inunctions. 



GLANDULAR FEVER 

Pfeiffer, in 1889, drew attention to the following clinical symptoms 
complex occurring in children of all ages: Sudden onset; high fever (104°); 
pain in the joints ; restlessness ; vomiting ; slight coryza and cough ; congested 
fauces; pain in the neck and on swallowing; constipation; large and painful 
lymph nodes in the whole circumference of neck, but particularly at the 
nape of the neck, generally on both sides. In the mild form the fever 
subsides on the second day and the glands gradually subside. The severe 
form may last from eight to ten days. Suppuration is rare. Nephritis 
is an occasional complication. 

Glandular fever appears to be an acute infectious lymphadenitis of 
obscure origin. The portal of entrance is probably the upper respiratory 
tract. 

The prognosis is favorable. 

The treatment is by rest in bed, a laxative daily enema, a daily 
warm bath, and fever diet. The nasopharyngeal toilet should be used. 



» 



MALARIAL AND TYPHOID FEVERS IN CHILDREN 207 

In protracted cases a few doses of sodium salicylate or quinine saccharinate 
may be given. 

MALARIA IN CHILDREN 

Malarial fever as an infectious disease is fully discussed in the chapter 
on Infectious Fevers. In older children this disease runs about the same 
course as in adults. In younger children we observe, first, the acute form, 
in which the onset is occasionally ushered in with chills or convulsions with 
coma (the cerebral type) ; second, the chronic form, in which the children 
are anaemic and frequently suffer from stomatitis with swollen lymph nodes 
and an enlarged spleen; and, third, the masked, or irregular, type. When 
an intermittency of fever is observed, it is usually of the quotidian or tertian 
type. Chills do not set in so abruptly as in adults, and the spleen is not 
regularly enlarged. 

Clinical Types of Malaria in Children. — 1. The cerebral type, of acute 
and subacute onset with high temperature, convulsions, and coma. 

2. Malarial infection with bronchopneumonia. 

3. Malarial infection with acute enteritis. 

4. Malarial infection with torticollis. 

5. Malarial infection with acute and chronic nephritis. 

6. Malarial infection with a gradually developing endocarditis. 

7. Masked malaria (malaise, neuralgia, stomatitis with enlarged lymph 
nodes) . 

The masked types particularly are of daily occurrence in the practice 
of medicine in malarious districts. 

Diagnosis. — The diagnosis is established by means of a blood examina- 
tion (see Laboratory Diagnosis) and also by means of the therapeutic test, 
i. e., the administration of quinine sulphate or "sweet quinine " in 3 to 5 
gr. doses. 

Treatment. — Quinine is a specific for malarial fever. Children take it 
in 2, 3, or 5 grain doses twice or three times a day. In order to disguise 
the bitter taste to some extent, it is best given in suspension in compound 
elixir of taraxacum or in honey. Fluid extract of licorice or elixir of yerba 
santa will also hide the bitter taste of quinine salts. After the medicine is 
swallowed, older children may taken a lemon candy into the mouth to still 
further hide the taste of the specific drug. 

Sweet quinine (saccharinate of quinine) is now obtainable. It has about 
the same strength and therapeutic value as the bitter sulphate. It may 
be given in compressed tablets. 

Euquinin is a quinine preparation adapted for children. It is given in 
the same dose as the sulphate of quinine. 

TYPHOID FEVER IN CHILDREN 

Typhoid fever is comparatively rare in infants, but it is more frequently 
met with in older children ; it is usually of a mild character, although cases 
of a severe type do occur. The diagnostic features and treatment are similar 
to those in adults. (See Typhoid Fever.) 



208 PAEDIATRICS 



VULVOVAGINITIS 



We observe three varieties of vaginal discharge in children: 

A simple leucorrhoea is not an uncommon occurrence in anaemic or ill 
eared for little girls, and usually subsides as soon as local cleanliness and 
proper hygienic and tonic management are inaugurated. 

The simple purulent vulvovaginitis, as observed in little girls, may be 
due to mechanical irritation, masturbation, worms, or uncleanliness, or may 
follow exanthematous diseases, and sometimes it arises without apparent 
cause. It shows no tendency to spread into the bladder or pelvis, but it 
is communicable and may give rise to inguinal adenitis, mild purulent oph- 
thalmia, or a pustular eczema on account of scratching with unclean fingers. 
The distinction of the simple purulent vulvovaginitis from the specific, 
or gonorrhoeal, variety is accomplished with the aid of the microscope. 

Treatment. — The parts must be carefully cleaned by wiping the dis- 
charge away with moistened absorbent cotton and douching with a sal 
soda solution and afterward with sulphocarbolate of zinc, 5 per cent solution, 
or 5 per cent alum water. When the parts appear much irritated, stearate 
of zinc should be dusted between the labia. Worms, if present in the 
intestines, should be discharged. 

Specific, or Gonorrhoeal, Vulvovaginitis. — This variety is due to the 
presence of a diplococcus (see Laboratory Work), is highly contagious, and 
may give rise to severe gonorrhoeal ophthalmia, suppurative inguinal adeni- 
tis (bubo), cystitis, pyosalpinx, pericarditis, pelvic or general peritonitis, 
and gonorrhoeal arthritis with severe heart complications. In recent cases 
the infected vaginal mucous membrane is swollen, bleeds easily, is eroded 
in places, and is covered with a foul smelling purulent discharge. 

Regarding the mode of infection, it may be stated that in children of 
both sexes the usual mode of infection is responsible for the disease in some 
few cases. The majority of cases may be traced to the child's sleeping in the 
same bed or playing with and touching a person suffering from gonorrhoea. 
In some instances soiled linen and water closet seats and Infected catheters 
have been held responsible. Infection will often lurk in the vulvovaginal 
gland and its duct, in the urethral follicles, and in the deeper recesses of 
the vagina, although the more accessible, visible parts are in a healthy 
condition on ordinary examination. Thus, we have latent, or unsuspected, 
vulvovaginitis, which may start up again at any subsequent time and give the 
impression of a new acute attack. Therefore the presence of gonorrhoeal 
discharge in a little girl, without marks of injury to the genitalia, does not 
prove a recent acute infection or that an assault has been attempted. 

Treatment. — The parts must be cleansed frequently, as already de- 
scribed, and the vagina thoroughly swabbed with a 2 per cent protargol 
solution on a cotton carrier twice a day or a 2 per cent nitrate of silver 
solution. An atomizer may also be used to advantage, and over night a 
protargol suppository may be inserted into the vagina, gr. j to grs. v protargol 
of cacao butter. If the application of the disinfecting agent produces 
severe smarting, it may be applied in less strength. 

The treatment after the first week should be less active, but should 
continue for from six to ten weeks. Even after the gonococcus has dis- 



FAMILIAR FORMS OF NERVOUS DERANGEMENTS 209 

t 

appeared from the discharge relapses are frequent. During the time of 
treatment the child must wear a pad. Cases occurring in the wards of a 
children's hospital must be strictly isolated. 

Vaginal douching with antiseptic solutions are occasionally followed 
by severe local pains in the pelvis and bladder, with a fever temperature. 
Careful douching with the fountain syringe but slightly elevated and the 
child in Sims's position is effective and devoid of danger. With proper 
treatment and when precautions as to complications are taken, the prognosis 
is good. A complete and" rapid cure should not be promised. In young 
girls, in lieu of the fountain syringe for purposes of irrigation, a small soft 
catheter attached to a piston syringe should be employed. As an irrigation 
fluid permanganate of potassium, 1 to 4,000, may be used. At first two 
injections should be made daily; subsequently one a day; and finally two 
or three a week. After irrigation the parts should be dusted with stearate 
of zinc and a gauze pad applied. 

The early detection of vaginal discharges of gonorrhoeal origin in young 
children in day nurseries, kindergartens, and primary classes in public 
schools is of the utmost importance in preventing the spread of this malady 
and its complications, such as contagious ophthalmia, etc. To illustrate 
the dangers of gonorrhoeal infection in children in public schools, the fol- 
lowing authentic instance is cited: In a public institution in New York 
City harboring 850 children, 130 cases of so called leucorrhcea developed in 
two months, which proved to be gonorrhoeal in nature. A large number 
of these children attended public schools. After numerous complaints by 
parents of children subsequently infected had been made, the matter was 
carefully investigated and proper isolation was effected. 

MASTURBATION IN INFANTS (THIGH FRICTION) 

An early recognition of this habit is important, inasmuch as the practice 
can easily be stopped in the beginning, whereas if it is neglected until the 
children are older, the habit is apt to become firmly established. Thigh 
friction can be prevented by any mechanical device which will keep the 
legs apart; but such a contrivance would be of no value in cases in which 
the child used its hand. For such cases a breech corset and leg separator 
combined would be necessary. Local irritation and irritation from highly 
acid urine should be recognized and treated, and general tonic management, 
including cold sponging, is indicated in cases of this nature. Masturbation 
in older children is overcome by tactful management by the parents 
and physician. Preputial adhesions are the most fruitful sources of local 
irritation. 

FAMILIAR FORMS OF NERVOUS DERANGEMENTS PECULIAR 

TO EARLY LIFE 

TICS; HABIT SPASMS; PAROXYSMAL RUNNING IN CHILDREN 

Facial tics, facial nerve, spinal accessory, and hypoglossus spasms 
(trigeminal tics) are due to some central or peripheral irritation, as are 
also the bladder tics and heart twitching. 
15 



210 PJEDIATRICS 

Habit Spasms. — Simple tics are under the control of the will to a certain 
extent. The muscles of the face, neck, shoulder girdle, arms, and legs are 
involved. Usually some source of irritation, such as adenoids or eye strain, 
can be elicited. They are annoying and very resistant to treatment, and 
may be associated with explosive utterances and cries and imperative ideas, 
or show as complex coordinated tics, such as head nodding and head banging. 

Psychic tics, or imperative ideas, impelling the victim to touch a certain 
object or count a certain number, etc., are not serious. 

Paroxysmal running is a morbid phenomenon of the explosive sort, 
suggesting cerebral excitation. The running may be in a straight line, in 
large circles, or irregular. There are two types: The first is associated 
with such diseases as epilepsy and mental derangement; the second is 
associated with chorea or hysteria. An underlying neurotic constitution 
is at the bottom of all tics, and in many instances some local irritation can 
be determined. Children of alcoholic and syphilitic parentage are prone 
to show tics. Anaemia and malnutrition intensify the liability to tics. 

Treatment. — Neurotic children should not be overlooked at school, 
and should have cold douches up and down the spine, gymnastics, fresh air, 
proper food, and no intercourse with neurotic or violent individuals. In 
local tics the source of irritation, eye strain, phimosis, or adenoids must 
be remedied if possible. Local vibration and vibration along the spine are 
indicated. 

HEAD NODDING AND NYSTAGMUS IN RHACHITIC CHILDREN 

Under the titles spasmus nutans, nictitatio spastica, etc., writers have 
reported cases of clonic spasms of a group of muscles innervated by the ac- 
cessory nerve, notably the sternocleido mastoid, trapezius, and recti capitis 
muscles. This muscular unrest may be unilateral or bilateral, and ceases 
during sleep. Nothing is known as to the aetiology of this condition. In 
severe cases of long standing the prognosis is unfavorable, and the treat- 
ment is limited to the removal of any form of reflex irritation which may 
be present or is supposed to exist, plus hygienic management and the 
medication recommended for rhachitic conditions. Two cases which came 
under the author's notice presented features not hitherto described (Trans, 
of the Amer. Pcediatric Soc, 1889). 

Tbe first case referred to was that of a child eleven months old, in which 
the choreic movements were noticed by the mother on the day following 
an injury to the head by falling from a high chair. The muscles supporting 
the head were in such a state of unrest as to seriously interfere with the 
comfort of the child. The child soon became peevish, refused to take food, 
and became emaciated in appearance. A careful examination showed a 
marked rhachitic development and nystagmus of the horizontal type. 
The eyes were examined by competent ophthalmologists. Dr. Roller, Dr. 
Schapringer, and Dr. E. Fridenberg, and, excepting nystagmus, nothing 
abnormal was detected. It was furthermore noticed that if the child's 
attention was engaged by a shining object held at some distance above 
the level of the eye, the nystagmus and choreic movements would cease 
during such fixation. It was also apparent that the moventents of the head 



I 



TETANY IN INFANCY (PSEUDOTETANUS) 211 

were not the consequence of muscular weakness, but, on the contrary, it 
seemed as though they were due to a distinct effort on the part of the child 
for the purpose of visual fixation, made difficult by the existing nystagmus. 

Treatment. — The application of an eye bandage suggested itself, and as 
soon as this was in such a position as to exclude every ray of light the choreic 
movements ceased completely; if, however, the bandage was so applied as 
to admit but very little light,the head movements persisted. This phenom- 
enon was observed by a number of my colleagues, and could be repro- 
duced at any time. Under such circumstances a permanent eye bandage 
suggested itself as a therapeutic procedure. The bandage was properly 
applied, and removed but once a week for cleansing purposes. The child 
was carried to the riverside daily, and was treated with salt baths and 
massage. The diet was regulated and phosphorus given internally. This 
treatment was faithfully carried out by the mother, and at the end of three 
months the nystagmus and choreiform movements had ceased, and the child 
was plump and healthy in appearance. 

In a second child the symptoms manifested themselves after an attack 
of measles. At the time of its presentation there were moderate con- 
junctivitis, the nystagmus of the vertical type, and the movement of the 
head. The treatment and ultimate good results were the same as in the 
first case. 

It appears from these observations that the localized tonic muscular 
spasms were either compensatory to the movements of the eyeball or reflex 
from irritation occasioned by the light to those structures which are con- 
cerned in carrying the impression. In view of the fact that the choreic 
movements ceased as soon as all light was excluded from the children's 
eyes, I am unable to formulate a more satisfactory explanation of the 
phenomena observed than the one I have expressed. 

NIGHT AND DAY TERRORS (PAYOR NOCTURNUS ET DIURNUS) 

Mild and severe cases of nightmare may be due to gastrointestinal or 
respiratory disturbance — nasal obstruction. In some instances of circu- 
latory disturbances consciousness is lost and the little patient appears to 
have no knowledge of the attack on awakening. In most instances there 
is an underlying neuropathic anaemic constitution. In the management 
of such cases it should be remembered that ill ventilated, dark rooms, late 
meals, exciting games, and story telling before bedtime favor the attacks. 
When night terrors are of central origin, they do not yield to ordinary 
hygienic management, and must be regarded with gravity. 

TETANY IN INFANCY (PSEUDOTETANUS) 

In the present state of our knowledge tetany may be defined as symp- 
tomatic intermittent paroxysmal muscular rigidity occasionally observed 
(1) in rhachitic infants and children, (2) in cases of intestinal putrefaction 
and autointoxication, and (3) as an associated feature or sequel of acute 
infectious fevers. In a study of seventy-one cases reported by Dr. R. A. 
Peters (Roussky Vratch, September 14, 1902), the following symptoms 



212 PAEDIATRICS 

were noted: 1. Contraction of the hands and of the feet. 2. Chvostek's 
symptom: Percussion with a hammer over the branches of the facial nerves 
produces a contraction of the facial muscles. 3. Erb's symptom: Increased 
electro irritability in the peripheral nerves. 4. Trousseau's symptom: 
Pressure upon the tendon of the biceps produces contractions in the muscles 
of the upper extremity that are quiet at the time of testing, or the con- 
tractions are increased in those muscles that are in activity at the time. 
5. A sign which the author calls "jumping jack " symptom. It consists 
of motions of the lower extremities resembling those that result from the 
pulling of a string of a paper "jumping jack " when the galvanic current 
is applied to the portions of the spine that correspond to the lumbar and 
cervical enlargements, the anode being placed on the chest, the cathode on 
the spine. The strength of the current was from three to four milliamperes. 
Erb's and Chvostek's symptoms were not found so constantly as the other 
signs, and were not pathognomonic. 

Prognosis. — With proper management the majority of the patients re- 
cover. 

Treatment. — Warm baths, enteroclysis, warm peppermint tea as a bev- 
erage, and proper food, together with mild massage, should be the thera- 
peutic measures. In severe cases bromide of potassium, chloral hydrate, 
chloroform inhalations, and morphine subcutaneously, gr. ^^ to -^, also 
subcutaneous injections of \ per cent carbolic acid water, 30 drops three 
times daily, may be used. 

LARYNGISMUS STRIDULUS (LARYNGOSPASM) 

Laryngismus stridulus is a laryngo respiratory spasm (neurosis) occurring 
in rhachitic children. It is characterized by a sudden holding of the breath 
with inspiratory stridulous breathing, and is common in children from one 
to two years of age. In severe attacks the patient becomes cyanotic and 
occasionally goes into convulsions. The attacks come on at odd times 
during the day and can often be provoked by passing the finger down into 
the throat. There is no fever, coryza, cough, or catarrh of any kind asso- 
ciated with this condition, except when the patient is afflicted with adenoids 
or large tonsils, in which case catarrhal symptoms are often observed. 
Enlargement of the thymus has been suggested as playing an setiological 
role in laryngospasm. Very little experience will enable us to distinguish 
this form of laryngismus from stridulous breathing in catarrhal and mem- 
branous croup, spells of whooping cough, and hard breathing spells. 

Treatment. — The attack can be cut short by dashing cold water over 
the abdomen. The rhachitic condition requires proper food, cold sponge 
baths, massage, change of air, and 10 drops of Thompson's solution of 
phosphorus three times a day. Bromides, chloral, and musk may be tried. 
Adenoids must be removed and the nasopharynx kept free by dropping 
salt water into each nostril three times a day or by using the albolene spray. 
In very severe cases the writer has employed vibration and tubed the 
larynx for hours or days, and apparently with good results. A fatal issue 
in laryngismus is a rare occurrence and comes unexpectedly. 



ENURESIS ; BED WETTING ; INCONTINENCE 213 

ENURESIS; BED WETTING; INCONTINENCE 

Enuresis, like convulsions, is a symptom. This annoying condition in 
children is too well known to require specification. It may be designated 
as a habit spasm of the bladder and may be nocturnal or diurnal. Leaving 
aside the cases of organic disease of the brain and cord (idiocy) and of mal- 
formations of the urethra and bladder, we may safely assume that enuresis 
in childhood must be classed as a neurosis to the extent that in individuals 
some form of reflex irritation produces the involuntary discharge of urine 
from the bladder. The conditions of malnutrition and anaemia frequently 
found associated with enuresis may and may not intensify the reflex irrita- 
bility of an individual. It is well known that in extreme forms of mal- 
nutrition and marasmus there is a well marked obtuseness of the nervous 
system. 

There are a great many varieties of enuresis. The following list embraces 
the ordinary conditions found in children in cases of enuresis. Malforma- 
tions of the urethra and bladder and organic disease of the brain and cord 
(idiocy) are not included in the list. 

Clinical Varieties of Enuresis. — Bed wetting with Digestive disturb- 
ances; large evening meal; a full bladder at night from too much water 
taken before bedtime; an abnormal condition of the urine, crystals in 
the urine; constipation; foreign bodies in the bladder, rectum, or urethra; 
a small meatus; phimosis, an adherent prepuce or clitoris, and elon- 
gated prepuce, a short frenulum; erosions and inflammations of the pre- 
puce, glans, vulva, or urethra; warts of the glans, prepuce, or vulva; 
urethral caruncle; polyps, fissures of the rectum; worms in the rectum; 
masturbation, thigh friction; hernia, hydrocele; undescended testicle; ade- 
noid vegetations, mouth breathing; cystitis (bacteriuria) ; bed wetting in 
diabetes, rhachitis; anaemia. 

Prognosis. — Enuresis may last only a short time or continue on and 
off up to puberty. 

Treatment. — There is no routine treatment for enuresis and it is a 
fallacy to look around for a drug which will cure bed wetting. 

1. The main point is to combat the neuropathic constitution and mal- 
nutrition by cold sponge baths, proper feeding, general massage, and exer- 
cise in the fresh air. 

2. To examine the blood for anaemia and, if it is present, give iron and 
arsenic, and order fresh air and a daily flushing of the colon with warm saline 
solution. 

3. To look for and remove if possible local irritation as pointed out in 
the list of Clinical Varieties. 

4. If no local disturbance is detected, it is admissible to pass a clean 
sound and stretch the urethra, which is sometimes the seat of invisible 
erosions, stricture, or spasm. 

5. Bromide of potassium and belladonna may be given after al^ else has 
failed to relieve the excessive irritability of the nerve centres, also chloral 
hydrate. 

6. Some relation between mouth breathing and bed wetting exists. 
Large tonsils and adenoids should be removed. 



214 PAEDIATRICS 

7. Elevating the foot of the bed at night sometimes overcomes enuresis 
by taking away irritation from the neck of the bladder. Hot sitz baths 
may be given before bedtime, and vibration along the spine and over the 
bladder may be applied every other day. 

CONVULSIONS IN CHILDREN 

Convulsions are symptomatic of some disturbance, but may be treated 
from the clinical standpoint as a separate affection. In children clonic 
convulsions are always accompanied by loss of consciousness; in adults 
convulsions may be simulated. Older children of neurotic environment 
and constitution may have tonic contractures without true loss of con- 
sciousness. We speak of tonic and clonic, general and localized, con- 
vulsions. Convulsions are common in rhachitic, neurotic, tuberculous, 
and syphilitic children. On the other hand, long continued profound 
malnutrition shows an obtuseness of the nervous system. Congenital 
contractures point to convulsions in utero. 

Motor discharges have their origin in the nerve cells, in the cortex, at 
the base of the brain, in the pontobulbar region and Rolandic cortical area, 
in the ganglion cells of the brain, or in reflex centres in the pons and medulla. 
An autopsy generally shows no changes except hyperemia, and the real 
changes are probably in the cells. Irritation of the motor centres may 
be direct, as in: Injuries at birth; haemorrhage; tumors; abscess; thrombosis; 
embolism; encephalitis; meningitis; sunstroke, etc.; or irritation of the motor 
centres may come indirectly through the circulation, as in: Anaemia of the 
brain; hyperaemia or venous congestion, as in heart disease, asphyxia, 
laryngismus, and pertussis; uraemia; poisons, vegetable, mineral, animal; 
toxines, infectious fevers; autointoxication from poisons formed in the 
intestines, urine, or blood (paraxanthin, acetone, etc.). 

Irritation of the motor centres may come as a simple reflex irritation, 
as from a foreign body in the nose, ear, pharynx, etc.; earache; gastro- 
intestinal irritation, colic; fright, anger, burns, wounds; retention of urine; 
renal and intestinal colic, etc. 

Convulsions in infectious fevers have a twofold significance. At the 
onset they denote overwhelming toxaemia, but do not necessarily involve 
a grave prognosis. When convulsions set in at the termination of a severe 
illness, it means some complication or circulatory failure, with inanition of 
the brain. During the convulsive attack the temperature may be normal 
or elevated. A convulsive seizure may be followed by coma, semicoma, 
rigidity, or paralysis, and occasionally death. 

Prognosis. — The prognosis is governed by a knowledge of the exciting 
cause. 

Treatment. — In the majority of cases convulsions in children are due 
to some gastrointestinal disturbance or to the onset of an acute infectious 
disease. The momentary treatment is entirely symptomatic. In many 
instances such prodromal conditions as twitching with restlessness and high 
temperature will warrant the administration of a bath and an enema. A 
child in a paroxysm should receive an enema at once, and be put into a 
bath 100° F. After removing the patient from the bath, an ice cap is 



. CHOREA (ST. VITUS'S DANCE) 215 

applied to the head and the patient put to bed and kept quiet. Should 
the convulsions return, the bath and enema are repeated, and chloral 
hydrate with potassium bromide (each,gr. 1 to 3) may be given by the mouth 
if the patient is conscious, or by the rectum if he is comatose. If a very 
high temperature is present, hydrotherapeutic measures for reducing tem- 
perature are indicated, or a single dose of antipyrine in water may be 
given per rectum. 

In obstinate and prolonged convulsive seizures the inhalation of chloro- 
form and the hypodermic administration of morphine (gr. -^^ to y^) 
are justified. If, on the other hand, the convulsions are caused by heart 
failure, camphor, strychnine, whiskey, and digitalis may be given sub- 
cutaneously in connection with enteroclysis. After the child's recovery 
from an attack the physician will direct his attention to any underlying 
or predisposing cause. In obscure cases it may be advisable to tap the 
spinal canal for diagnostic purposes. 



CHOREA (ST. VITUS'S DANCE) 

Chorea belongs to the group of psychomotor neuroses of unknown ori- 
gin, and occurs most frequently between the ages of five and fifteen. It 
is a disease characterized by irregular and involuntary muscular movements 
without loss of consciousness, affecting the muscles of volition, frequently 
associated with systolic heart murmurs, and having some obscure connec- 
tion with endocarditis and rheumatism. As the origin and pathology of 
chorea are still a terra incognita at the present time, its setiology will not be 
discussed here beyond stating that overpressure at school and fright are 
important factors in its production, and that neurotic, anaemic, and ill 
nourished children are most liable to be afflicted. 

Clinical varieties of chorea are symptomatic chorea, caused by material 
lesions in the brain ; reflex chorea, due to reflex irritation, and idiopathic 
chorea, due to infectious and toxic influences, e. g., rheumatism. The last 
variety is the most frequent and important, and may be looked upon as an 
infectious disease or intoxication by the products of pathogenic bacteria. 

Sjrmptoms and Course. — Chorea may be general or partial. Its course 
may be acute, subacute, or chronic. It rarely affects children under five 
years of age. The attack comes on gradually, as a rule. The child appears 
nervous and depressed, drops things held in the hand, or stumbles and falls 
or makes grimaces. Such manifestations may be one sided (hemichorea). 
The child is irritable and emotional and has difficulty in speaking. There 
is tongue tremor with inability to hold the hand out straight and motionless. 
Systolic heart murmurs are frequently heard. 

In the so called posthemiplegic "chorea," the muscles are rigid and 
contracted and the reflexes are increased. 

Prognosis. — Complete recovery is the rule. Acute chorea plus endo- 
carditis may terminate fatally. The prognosis in cases complicated by 
a cardiac murmur should be guarded. Relapses of the choreic condition 
are not infrequent. 

Management and Treatment. — A child affected with chorea should be 
put to bed and have no visitors or excitement, but be in charge of a 



216 PAEDIATRICS 

competent person to entertain and nurse him. A daily bath and daily 
soap suds enema are to be given. Should the child not get sufficient sleep, 
a dose of chloral and bromide must be administered at night. A light 
and nutritious diet must be arranged. Palpitation of the heart with some 
fever may indicate the administration of 

I^ Sod. salicyl., 5 j ; 

Potass, iodid., 5ss. ; 

Tinct. aconit. rad., gtt. xvi; 

Aquae et syrup, ad., 5ij. 

M. S.: A teaspoonful every two hours. 

Fowler's solution of arsenic, gtt. 2 to 5, in combination with 5 grains 
of bromide of potassium, may be administered in water three times a day. 
With a view to combating endocarditis, which is a frequent complication 
of chorea, an ice bag may also be placed over the chest. 

After recovery the child should be sent to the "country or seashore, 
and have mild general massage. In mild cases the children should be taken 
from school and given a change of air. When arsenic has been given to 
the point where gastric symptoms are manifested, its administration must 
be discontinued, and the following digestive may be given: 

I^ Acid, hydrochloric, or dil., 5j ; 

Tinct. gentian, comp., 5 j ; 

Ess. pepsin., 5iij. 

M.S.: A teaspoonful after eating. 

The use of arsenic may be resumed after the tongue is clean. In some 
cases vibration over the spine every other day for ten minutes has been 
followed by satisfactory improvement. 

THE PARALYSES OF INFANCY AND CHILDHOOD ^ 

Obstetrical paralysis of the face or arm is caused by injuries inflicted 
during labor, and is discussed in the section of diseases of the new-born. 

Little's disease is a congenital spasmodic paraplegia of the extremities, 
particularly the legs, capable of improvement and cure by general hygienic 
management and mild massage, though if syphilis is the underlying cause, 
mercury should be administered. 

Infantile Spinal Paralysis (Acute Anterior Poliomyelitis.)- — This ail- 
ment is most frequent between the ages of one and four years, and must be 
looked upon as an acute infection localized in the cord. The disease occurs 
sporadically and in epidemics. The onset is usually sudden, with fever, 
vomiting, diarrhoea, and prostration. Paralysis sets in shortly after the 
onset. When children are taken sick in the afternoon, the paralysis is 
generally manifest on the following day. There are no disturbances of 
sensation and the intelligence remains intact. One side or both sides may 
be paralyzed at the onset, but after a few months, even without treatment, 
we find the paralysis limited to a few muscles of one leg or arm. The 

' See also Neurological Memoranda. 



THE PARALYSES OF INFANCY AND CHILDHOOD 



217 



muscles are soft, never rigid, and show no tendon reflex, thus contrasting 
sharply with the rigidity of cerebral paralysis. Atrophy in infantile spinal 
paralysis is also marked. The lesion affects the growth of the paralyzed 
hmb, and the joints become lax. It has been noticed that those muscles 
recover which respond to the faradic current. The total absence of 
sensory symptoms is also characteristic of infantile spinal paralysis. 

Differential Points. — In discriminating between anterior poliomyel- 
itis and multiple neuritis following infectious disease (diphtheria and influ- 
enza), it will be well to remember that in the latter lesion the limbs are 
affected symmetrically, the muscles are tender, and in fact the sensory 
symptoms are severe. Paralysis, atrophy, 
reaction of degeneration, and loss of tendon 
reflex are present in both. 

Treatment. — The object is to increase 
the nutrition of the limb and protect it from 
injury. The paralyzed limb is cold and 
should be well wrapped during cold weath- 
er. Massage, gymnastics, hot and cold 
douches, and the interrupted or galvanic 
current and vibratory massage are indi- 
cated. If a brace is applied, it must be 
light and not cumbersome. Orthopaedic 
surgery has been invoked to overcome the 
paralytic club foot and contractures by 
tendon grafting and shortening of tendons 
and nerve anastomoses, and some note- 
worthy results have been obtained. 

Infantile Cerebral Paralysis with Re- 
tarded Development (Spasmodic Infantile 
Hemiplegia.) — Beginning more or less with 
brain manifestations, fever, delirium, con- 
vulsions, spasm, the paralysis is of the 

hemiplegic type, with rigidity, contracture, and exaggerated reflexes. The 
electrical reactions are normal, and there is no rapid or extreme wasting. 
Athetoid movements are noted in some cases, also posthemiplegic chorea. 
Protracted labor, instrumental injury, asphyxia, acute infection (scarlatina, 
diphtheria, cerebrospinal meningitis), cysts, and areas of softening and 
sclerosis are setiological factors. 

Prognosis. — Facial paralysis generally disappears, the leg improves, 
and the arm remains disabled. 

The treatment is the same as in the spinal paralysis, and in cases of 
doubtful origin the patient should have the benefit of the doubt and be given 
an inunction cure. 

Primary Myopathies. — Pseudohypertrophic muscular paralysis and atrophic 
myopathies are forms occurring in late childhood, usually beginning be- 
tween the ages of two and eight and affecting both sexes. Some form of 
motor weakness is generally the first symptom, and the way in which 
the patient raises himself from the horizontal to the vertical position is 
characteristic of the lesion. Owing to weakness of the extensor muscles of 




Fig. 92. — Pseudohypertrophic 
Muscular Paralysis. 
Trying to get up. 



218 



PEDIATRICS 



the knee, he places his hands on the lower part of the thighs and gradually 
raises himself upward by this assistance. The posture and gait are charac- 
teristic. When the patient is standing, the abdomen projects, the back 
is hollow, the buttocks are thrown back, the feet are planted apart, and the 
gait is swaying and waddling. There is feeble response to both currents 
of electricity. 

The PROGNOSIS of myopathic disease (atrophy or pseudohypertrophy) 
is not favorable. After the power of standing is lost, the case is practically 




Fig. 93. — ^Pseudohypertrophic Muscular Paralysis. 
Showing characteristic posture in trying to rise. 



hopeless, but no case should be pronounced hopeless until treatment has 

been persisted in on the following lines and with a view of exhausting the 

"specifics " before we give up all hope: 

Open the bowels to eliminate autoinfection from the intestine. 
Give general mild massage and baths to better the circulation, 
A course of antimalarial treatment, even if the plasmodium is absent 

from the blood, may be given. 



THE PARALYSES OF INFANCY AND CHILDHOOD 219 

A course of antisyphilitic treatment, with mercury and with potassium 
iodide. 

A course of antirheumatic treatment with sodium saUcylate. 

A course of treatment with thyreoid preparations. 

A course of treatment with suprarenal preparations. 

Pott's paralysis is common in childhood. It follows disease of the dorso- 
lumbar vertebrse, and its management is discussed under Orthopaedics. 

Diphtheritic Paralysis. — Postdiphtheritic paralysis may affect the mus- 
cles of the palate, the oculomotor muscles, the diaphragm and respiratory 
muscles, the muscles of the extremities (ataxia), and the heart muscle. 

The DIAGNOSIS is easy when the previous occurrence of diphtheria is 
known. Important symptoms are dysphagia, food regurgitation, a nasal 
voice, and a weak, loose cough. Primary paralysis of the palate has occurred 
as late as on the sixty-fifth day, primary oculomotor paralysis on the ninety- 
first day, and primary paralysis of other parts on the fifty-first day. Most 
of the cardiac paralyses occur between the fifth and tenth days ; a few cases 
have occurred even as early as on the second day, while this condition has 
occurred in a severe form (that is, ending fatally) in two cases on the fifty- 
fourth day and in one case, which ended in recovery, on the fifty-ninth day. 

The TREATMENT of these conditions is discussed in the chapter on 
Diphtheria. 

Pseudoparalysis in syphilitic, rhachitic, and scorbutic children is fre- 
quently observed. The extremities are affected, the sphincters are free, 
and the electrical examination is negative. In syphilis and scurvy pain 
is excited by moving the limb. In rhachitis the muscular weakness simu- 
lates paralysis. 

The TREATMENT is hygienic and dietetic, also specific in cases of known 
or suspected syphilis. 

Syphilitic Paralysis of Peripheral Origin. — The diagnosis of this condi- 
tion rests upon the fact of the integrity of the bones and upon the modified 
electrical reaction. When the signs of syphilis are not evident, the distinc- 
tion from infantile paralysis is made by the fact that the latter occurs 
suddenly, with fever, generalization of the paralytic phenomena, and 
absence of pain. 

Painful paralyses, or paresis in neuritis, may occur in children as well 
as in adults, usually from infection. The diagnosis is made from the pain 
and the rapid onset of the affection conjoined with the fact that there 
is no lesion of the joints or bones. 

Paralysis in the convalescent period of measles is of the paraplegic type, 
lasts about six weeks, and usually ends in recovery. 

Choreic paralysis is usually of the hemiplegic or monoplegic form, and 
most frequently occurs while chorea is present or during convalescence. 

Friedreich's disease, or hereditary ataxia, does not present phenomena 
of motor incoordination; there are nystagmus and disturbances of speech. 
It is not a congenital affection. The fulgurating pains, anaesthesia, and 
trophic disturbances of locomotor ataxia are wanting. Vertigo is present. 

Painful Paralysis of Young Children. — It is occasionally noticed that 
after a jerk or a twist an arm or leg is perfectly flaccid, and the children 
cry when the least movement is made, although there are no anatomical 



220 PEDIATRICS 

changes to be observed. Passive movements are perfect and ecchymoses 
are absent. Recovery is rapid, occurring in from one to eight days. Such 
injury is probably of the nature of traumatic neuritis, and mild daily massage 
is all the treatment that is necessary. 

Hysterical Paralyses. — In this form the reflexes are not abolished and 
the diagnosis is made by exclusion. 

The Causes which may Retard or Prevent Walking in Children. — The 
majority of children begin to walk between the tenth and sixteenth months, 
a few at eight months, and the most backward at the end of the second year, 
Any child who is unable to walk by the end of the second year will usually 
be found to be the subject of a pathological condition. The diseases which 
render a child unable to walk, or retard or otherwise interfere with that 
function, are rachitis, cerebral atrophy, cerebral sclerosis, hydrocephalus, 
meningitis, spasmodic hemiplegia, cerebral or cerebellar tumors, amyo- 
trophic lateral sclerosis, hereditary ataxia, infantile paralysis, chorea, and 
sometimes hysteria. In the diseases of the muscles there are also two which 
have a decided influence in interfering with the function of walking — pseudo- 
hypertrophic paralysis and a form of myopathy which begins in the lower 
limb. Lesions of the bones and joints have also an important bearing 
in this direction — namely, fractures, congenital or traumatic luxations, 
arthropathies, club feet. Pott's disease, and rhachitis, 

MENINGITIS IN CHILDREN 

The meninges respond to irritation like other serous membranes, and 
may become the seat of primary or secondary inflammation, accompanied 
by serous or purulent effusion. The same species of microbe which pro- 
duces a pneumonia or pleurisy may start a meningitis or synovitis, according 
to its localization. The infecting agent may reach the meninges through 
the blood or by extension from the nasopharynx, the ear, or the eye. 
Meningeal symptoms, such as delirium and slight rigidity of the neck, are 
often observed in acute infectious diseases. These are toxic phenomena 
(toxaemia), and must not be confounded with true meningitis. 

Simple acute meningitis is an infection of the pia mater by various 
microorganisms, including the pneumococcus lanceolatus. It may be primary 
or secondary to any form of infectious disease. The infecting agent may 
reach the pia through the circulation, or may be communicated by extension 
of a neighboring inflammatory process. The exudate may be serous or 
'purulent. When the exudate is absorbed, the membrane may remain 
thickened, as in pleurisy, and imbecility or idiocy result. 

The cerebrospinal meningitis is distinct clinically from the first mentioned 
variety, on account of its localization, as shown by the name, and because 
it shows a higher percentage of recoveries than any other variety of menin- 
gitis. It is looked upon as a diplococcus invasion of the membranes of 
the brain and spine, and occurs sporadically and epidemically. 

Tuberculous meningitis is an infection of the meninges by tubercle 
bacilli in the form of gray miliary tubercles. It is of frequent occurrence 
in children of two, four, or six years of age, and is also seen in older children. 
It is generally secondary to tuberculosis of some other organ, but clinically 



MENINGITIS IN CHILDREN 221 

it impresses one as starting primarily in the brain. Often there is a history 
of traumatism which seems to be the starting point of the disease. Infection 
takes place through the circulation or by extension from tuberculous ear 
disease or from tuberculous glands. The nasopharynx is believed to be a 
portal of entrance. 

Symptoms and Signs of Meningitis in General. — General malaise, 
drowsiness, vomiting, constipation, stiff neck and back, loss of control of 
the bladder and rectum, convulsions, delirium, coma, set eyes. 

The temperature ranges from 101° to 105°, 106°, and 107° F., or higher. 
The pulse at first is rapid, then irregular and slow. Cheyne-Stokes respira- 
tion is often observed. 

Symptoms of Tuberculous Meningitis. — First stage. The onset is usu- 
ally gradual. General irritability, loss of appetite and weight, pallor, low 




Fig. 94. — Cerebrospinal Meningitis. 

fever, and poor sleep are noted. These symptoms may extend over two 
or three weeks. 

Second stage. Excitation, vomiting, convulsions, irregular pulse and 
temperature, tache cerebrale, rigidity, tremor, and contracture. 

Third stage. Depression. Large, rigid pupils, slow, arrhythmic pulse, 
sighing respiration, strabismus, oscillating eyeballs, injected conjunctiva, 
hydrocephalic cry, Cheyne-Stokes respiration, delirium, convulsions, death. 

Differential Diagnosis. — In discriminating between the three forms 
of meningitis it will be well if we bear in mind that all the symptoms 
spoken of are the usual ones of a group of pathological conditions which 
we class under the heading of encephalo-meningitis, the aetiology of which 
embraces a variety of causes. 

1. Primary microbial infection, including the tuberculous variety. 

2. Secondary microbial infection, following any form of acute or chronic 
infection, including syphilis. 

3. Extension of a neighboring inflammatory process in the ear or nose, 
panophthalmitis, intracranial abscess, tumors, etc. 

When we are face to face with illness in which meningeal symptoms 
are noticeable, the first practical and important point to decide is as to 



222 PiEDlATRlCS 

whether or not there is meningitis. The question cannot be decided by 
taking into consideration any group of symptoms. A careful weighing 
of all the evidence is necessary. 

Vomiting, delirium, muscular rigidity, as symptoms of toxsemia, are 
j ust as pronounced in some cases of pneumonia, influenza, or eruptive fevers 
as in acute true cerebral or spinal meningitis. Malaise, vomiting, constipa- 
tion, low muttering, grinding of the teeth in sleep, injected conjunctiva, 
irregularity of the pulse, and sighing respiration are symptoms of long 
standing intestinal inertia and autoinfection as well as symptoms of tuber- 
culous meningitis. 

In meningitis we can generally elicit the tdche meningitique, or Trous- 
seau's sign, by drawing the finger nail sharply over the skin. Owing to 
vasomotor disturbances the red irritation mark comes slowly and disap- 
pears slowly. 

Kernig's Sign. — In cases of meningitis it is usually impossible for a 
patient lying on his back to flex the thighs upon the body without flexing 
the knee at the same time, and complete extension of the legs is impossible. 




l""iG. 95. — Meningitis. 

Both Trousseau's and Kernig's signs are occasionally found in patients 
not suffering from meningitis, and their absence does not positively exclude 
the diagnosis of meningitis. 

Spinal Puncture. — The cerebrospinal fluid obtained by puncturing 
the spine is cloudy or turbid in acute meningitis. In several cases of menin- 
gitis the writer has withdrawn pure pus by spinal puncture repeatedly, 
one child living three weeks in this condition. In tuberculous meningitis 
the fluid is very clear. The tubercle bacilli can seldom be found in the 
fluid by microscopical examination. If present, they are detected by the 
culture and inoculation tests. 

The prognosis is grave. Meningitis may progress for weeks and ter- 
3 



MENINGITIS IN CHILDREN 



223 



minate in recovery or death. When recovery occurs, blindness, muscular 
paralysis, speech defects, and defective intellect may remain. Meningitis 
may terminate in complete recovery. In the so called intermittent cases of 
cerebrospinal meningitis the prognosis is not unfavorable, and patients may 
recover completely from a clinical standpoint. 

In tuberculous meningitis the prognosis is unfavorable. 

The usual t3'pes of cerebrospinal meningitis are the mild, subacute, 
rapidly fatal, intermittent, and chronic. 

Treatment of Meningitis. — After the diagnosis is established, the treat- 
ment is symptomatic. Ice coil to the head; warm mustard baths, cool 
sponge baths. Fever diet: Milk, gruels, broths, tea, beef tea, eggs. In- 
unctions of mercurial or Crede ointment, 1 drachm twice daily. A daily 
enema of soap water or salt water, 1 drachm to 1 pint. Catheterism of 
the bladder in cases of retention of urine. Feeding by gavage in coma. 
Feeding per rectum. Spinal puncture to relieve pressure symptoms. 
Stimulation p. r. n. Tincture 
of iodine to check vomiting, 1 
drop in sweetened peppermint 
water every two to three hours. 
Sodium salicylate, 5 to 20 
grains, in water, per rectum, 
three times a day. 

A so called fever diet is 
essential in all febrile disease 
or conditions. The food should 
be fluid or semisolid, so as not 
to overtax the feeble digestive 
apparatus or leave a large resi- 
due in the intestine for decom- 
position, which would be apt 
to favor autointoxication or 
local irritation. 

For older children, who no 
longer take the bottle, we may 
select food from the following 
list: Water, toast water, fari- 
naceous water, gum arable 
water, white of egg in water, 
peppermint tea, imported gin- 
ger ale, black tea, milk, mat- 

zoon, kumyss, buttermilk, whey, sterilized. Pasteurized, or peptonized 
milk, malted milk, beef broth, mutton broth, chicken broth, with and 
without eggs, beef jelly, soups, gruels, cornstarch pap, pea soup, burnt 
flour soup, eggnog, tropon or somatose in peppermint tea, custard, ice 
cream, water ices, orange or pineapple juice, unfermented grape juice, etc. 

Indications for Gavage. — When the patients refuse to take food 
or are comatose and when rectal alimentation is inadequate. 

* Seibert claims excellent results from large doses of sodium salicylate 30 grains three 
times a day per rectum. 




Fig. 96. — Spinal, Punctuke. 
Position. 



FoKWARD Bicycle 



224 



PEDIATRICS 



Rectal Alimentation. — Nutrient Enemas. — Feeding by the rectum is 
useful in feeble digestion and in cases in which food is not tolerated by the 
stomach or to supplement a feeble stomach or in inability to swallow, etc. 

Antipyretic Measures. — Where the temperature is very high a warm 
bath (95° to 100° F.) may be given, and cold water may be added 
to the bath until the temperature is reduced to 75° F., or a cool sponge 
bath may be given several times a day, supplemented by an ice bag to the 
head. Drug antipyretics are hardly ever called for. 

Cerebral restlessness is best treated by cooling baths and by chloral 
hydrate, and bromide of sodium by the mouth or per rectum. 

Stimulation is best accomplished by means of enteroclysis (high enemata 
of salt water at 110° to 120° F.). Of stimulant drugs, we may employ 




Fig. 97. — Ice Water Coil in Meningitis. 

camphor and strychnine. Camphor may be given in one-half to one grain 
doses, hypodermically, dissolved in oil (one fifteenth). 

Local Treatment. — In meningitis local treatment has been attempted 
by the author by injecting iodoform, potassium iodide, and sodium salicylate 
into the subarachnoid space without beneficial results. ^ Patients with 
cerebrospinal meningitis frequently recover after the administration of 
salicylate of sodium and bromide of potassium internally. 

In 1902 Seager, of Lisbon, suggested local treatment in cerebrospinal 
meningitis by means of lumbar puncture and injections of 10 c.c. of a 



^ Trans, of the Am. Peed. Soc. 



HYDROCEPHALUS 



225 



1 per cent solution of lysol. 
experience. 



It has not proven of value in the author's 



HYDROCEPHALUS 

Hydrocephalus may be congenital or acquired. 

Congenital Internal Hydrocephalus. — We do not know the cause. It has 
been noticed in several members of the same family. Syphilis is an un- 
doubted factor. It is principally the lateral ventricles which are affected, 
and they may be so distended as to thin out and stretch the cerebral cortex 
over them to less than a quarter of an inch in thickness. The skull becomes 
enormously enlarged, the su- 
tures and f ontanelles are widely 
distended, the bones of the 
cranium are thinned, and the 
orbital plates may be so pressed 
forward as to cause exophthal- 
mus. The distending fluid is 
clear and contains traces of 
albumin and salts and some- 
times urea. 

Labor may be interfered 
with by the large head. In 
some cases the head does not 
become enlarged until several 
weeks after birth. Irritability 
and restlessness are prominent 
symptoms. The child is usu- 
ally not bright mentally and 
most generally shows some 
degree of imbecility. The legs 
may be feeble and show ex- 
aggerated reflexes, making it 
difficult for the child to learn 
to walk. Strabismus and optic 
nerve atrophy may develop, 
and nystagmus is usually seen. 

Ultimately there are convulsions, vomiting, and coma, and the child sel- 
dom lives to be more than three or four years old. 

Acute hydrocephalus (serous meningitis), alluded to under simple 
meningitis, is often secondary to a basilar meningitis. There is rarely very 
great distention, about three or four ounces of water being present usually. 

Acquired Internal Chronic Hydrocephalus. — The causes are compression 
or obliteration of the straight sinus or of the passage from the third to the 
fourth ventricle by a tumor or some obstructing local inflammation fol- 
lowing a meningitis. Some cases arise without known causes (serous 
apoplexy) . 

Symptoms. — They are obscure; headache, optic neuritis proceeding 
to atrophy, and attacks of stupor are usually noticed. The head does 
16 




Fig. 98. — Hydrocephalus. 



226 PEDIATRICS 

not enlarge, and there are no localizing symptoms. The diagnosis is seldom 
made during life. 

Treatment of Hydrocephalus. — This is largely mechanical. Gradual 
compression may be made by means of strips of adhesive plaster crossed 
in various ways. The symptoms of pressure may be relieved by withdraw- 
ing small quantities of fluid from the ventricles from time to time by means 
of an aspirating needle. Lumbar puncture of the subarachnoid space, 
permitting a slow escape of the fluid, may be practised without risk to the 
cord and without much danger of collapse. Medicines are apparently use- 
less, although mercurial inunctions and potassium iodide may be tried in 
cases of suspected syphilis. Drainage by means of a silver cannula con- 
necting a ventricle with a vein has been practised without satisfactory 
results. 

Chronic external hydrocephalus is exceedingly rare, and probably is 
always secondary. It is associated with some congenital malformation 
or atrophy of the brain, and may follow meningeal haemorrhage or pachy- 
meningitis. The fluid is confined beneath the dura mater, which, when 
incised, allows of the escape of a few ounces, sometimes as much as a pint. 
There is flattening of the convolutions, and sometimes there is atrophy. 
Some internal hydrocephalus may be present. The fluid may cause enlarge- 
ment of the head, separation of the sutures, and in fact most of the appear- 
ances of the internal variety. As a rule, it is not severe enough to give rise 
to any decided symptoms. 

DISORDERS OF SPEECH; STAMMERING, STUTTERING, AND LISPING 

When disorders of speech take their origin in the nerve centres, treat- 
ment or training will avail but little. When tongue tie, adenoid vegetations, 
irregular teeth, or cleft palate are causes, the stammering, stuttering, and 
lisping are easily remedied. Systematic teaching and training may over- 
come speech defects when they are due to a failure on the part of the vocal 
organs to cooperate with those of articulation. Tremor following severe 
acute illness or nervous shock or overwork or general debility will require 
constitutional treatment. 

HYSTERIA IN CHILDREN 

Hysterical Paralyses, Aphonia, Neuralgia, Contractures, H3rperaesthesia, 
Holding the Breath. — Psychical, sensory, and motor phenomena of a morbid 
character are common from infancy through childhood in anaemic children 
having neurotic parents or neurotic surroundings, in the offspring of al- 
coholics, and as complications of acute disease. Hysterical manifestations 
are possible as soon as the child has acquired the capacity to receive im- 
pressions and develop conceptions. 

In discriminating between hysteria and organic disease it is a great 
mistake to underestimate the shrewdness of a child, and the physician will 
readily deceive himself in diagnosis and thwart himself in the way of moral 
treatment if he unthinkingly makes the child or its hysterical mother a 
confidante of his views. 





Fig. 99. — One year old. 



Fig. 100. — iSaiue ciuld. Pronounced cretin at 
two years. 




Fig. 101. — Same child. 1 dui i\t,-cn.:> uuer treat- 
ment with thyreoid. 




Fig. 102. — Same child. Ten weeks after 
treatment with thyreoid. 



Figs. 99-102.— Spor.^dic Cretinism. (Case of Dr. H. B. Sheffield.) 227 



228 PEDIATRICS 

Hysterical and epileptic conditions blend and alternate, and the line 
of demarcation is exceedingly vague. It is therefore useless to go into 
details regarding diagnosis, because such matters will be decided by the 
acuteness and tact of the medical attendant, and not by a pen picture of 
conditions by no means clear cut. 

Prognosis is good, but there is a tendency to relapse. 

Treatment. — Rational hygiene and the handling of hysterical children 
by a kindly, firm, and intelligent woman is a conditio sine qua non of success- 
ful management. Self-control must be developed. Massage, cold baths, 
and gymnastics are indicated, and punishment is often a necessary feature 
in the treatment. As chronic intestinal indigestion is at the bottom of 
many ailments, every effort should be made to secure normal digestion for 
the child. 

MENTAL DEFECTS FROM ARRESTED DEVELOPMENT 
Idiocy; Imbecility; Cretinism; Mutism 

The idiot represents the lowest expression of human intelligence. In 
the scale of mental power and activity the imbecile stands between the 
idiot and the feeble minded, and about 5 per cent of imbeciles present 
the so called Mongolian type of imbecility. Such conditions are congenital 
or acquired. Imbeciles and feeble minded children may be developed 
along the line of their unimpaired faculties by special training if removed 
from the influence of neurotic parents. The mentally deficient are divided 
into the three following classes : 1 . Congenital mental deficiency in its various 
forms of microcephalus, hydrocephalus, the Mongol type, scrofulous cases, 
birth palsies with athetosis, cretinism, and primarily neurotic cases; 2. 
Developmental cases; 3. Accidental or acquired cases, consisting of trau- 
matic, postfebrile, emotional, and toxic varieties. 

Mutism may depend upon absolute deafness, mechanical defects of the 
speech apparatus, or mental defects. 

It is not generally realized how much moderately deaf children are 
handicapped in the acquisition of language and general information. 

Cretinism is faulty development in connection with some abnormality 
of structure or function of the thyreoid gland. Thyreoid medication has. 
achieved some remarkable results in cretins, and has been of some benefit 
in imbeciles and feeble minded children in which the signs of cretinism are 
absent. From two to five grains of the powdered desiccated sheep's thyreoid 
gland may be given for a long time. (See also Diseases of the Ductless 
Glands.) 

Amaurotic family idiocy is the' unfortunate name given to a symptom 
complex of brain degeneration in which inability to hold the head up and 
blindness are the marked features. Children so afflicted generally die 
before the age of two. The treatment is symptomatic and unavailing (see 
also Neurological memoranda). 



I 



CHAPTER IV 
THE DIGESTIVE SYSTEM 

NUTRITION AND DIET 

Synopsis : Introductory Remarks. — Digestibility of Food. — The Absorption of Food. — 
Constituents of Food. — Fuel Values of Food. — ^Tables of Calories (Fuel Values). — 
Practical Dietetics. — Fluid Diet ; Soft Diet ; FuU Diet ; Restricted Diet ; Fever Diet, 
etc. — Stimulants and Beverages: Alcoholic, Non- Alcoholic, Mineral Waters. — Pre- 
digested Food. — Concentrated Food. — Systems of Diet: Banting, Ebstein, Oertel, 
Schwenninger, Weir Mitchell. — Vegetarianism. — Exercise and Diet. — ^Tobacco and 
Digestion. 

INTRODUCTORY REMARKS 

The general practitioner is constantly confronted with the question of 
what foods shall be allowed or not allowed in the management of various 
acute and chronic disorders, and there is probably no subject related to 
the practice of medicine in which there is a greater lack of agreement than 
that of nutrition and diet. Nervous dyspeptics are kept upon a liquid diet 
until they are wrecks, young children and adults are fed with pancreatized 
food until the gastroenteric tract is foul and putrid, green salads are pro- 
hibited to convalescents whose system craves them, and in general the 
patient encounters such a complexity of diet regulations as to thoroughly 
bewilder the unfortunate individual who runs the gamut of a number of 
medical men. For this reason the writer has thought it proper to devote 
some space to practical dietetics. In developing rational dietetics we are 
guided by our known principles of metabolism and the fuel value of food 
and by the maxim that the true principles of dieting in disease must be 
in accordance with the dictates of common sense. 

Nature's indications as regards diet relate to appetite and the sense of 
taste as regulated by individual experience. Natural craving for a certain 
food is not necessarily morbid in disease and should not, as a rule, be opposed. 
To the healthy person the natural demands of the appetite are the best 
guide for quantity and quality, and a mixed animal and vegetable food is 
the best diet. 

In disease instinct may fail to express the proper needs of the system, 
and the knowledge and judgment of the physician will be called for. 

The exigences of life have established the routine of three meals a day, 
but in many eases dyspeptics of sedentary habits might with profit go back 
to nature and eat only when they had the desire for food. 

229 



230 THE DIGESTIVE SYSTEM 

REMARKS ON DIGESTIBILITY OF FOOD 

Beef possesses great nutritive power and furnishes the most palatable 
and appetizing broth. Salted meat is less nutritious than fresh, because 
the brine extracts from the muscular tissue some of its nutritive principles. 
Next to beef in nutritive value come mutton and venison, then the flesh of 
fowls, the various kinds of game birds, and lastly fish. The difference be- 
tween white meat and dark meat as regards digestibility is too trivial to 
be of practical importance. Fish is slightly nutritive, but easily digestible. 
Its exclusive use would produce a diminution of the muscular force, paleness 
of the tissues, and all the signs of subalimentation. The flesh of shell fish 
is hard of digestion. Roast meat is more digestible than boiled meat. Eggs 
very slightly cooked are more digestible than white meats. Of vegetables, 
the succulents are the most digestible. New bread is heavier than stale 
bread. The aliments to which the cook's art gives a liquid or semiliquid 
form are, in general, more digestible than others. Both reason and expe- 
rience show that Nature's liquid and semiliquid foods, milk and eggs, are 
particularly adapted for a feeble digestion during the course of febrile dis- 
ease. Of the vegetable class, lentils, beans, and peas are the most nourish- 
ing. Fruit, when perfectly ripe, is easy of digestion, because the juice of 
fruit consists of pure grape sugar (glucose) and water, and it is in the form 
of grape sugar that all starchy food is finally absorbed into the system. 

THE ABSORPTION OF FOOD 

Although we possess considerable knowledge regarding the absorption of 
food and the quantities necessary to sustain life, our knowledge of the ul- 
timate processes of assimilation and dissimilation is meagre. The animal or- 
ganization requires constant feeding with water, salts, and organic materials 
— proteids, carbohydrates, and fats. The proteids are tissue builders. 
The carbohydrates are energy producers. Without proteid material in 
some form life cannot be sustained. The amount necessary depends upon 
individual disposition and upon individual expenditure of heat and force. 
An inadequate supply of food from loss of appetite or poverty leads to 
inanition; and, if the animal organism does not get the adequate amount 
of food, it burns its own material. Thus some parts of the organism are 
sacrificed to preserve the whole. The first to be used up are the fat and sugar 
(glycogen), and finally the albuminoids, or Jiving tissue. Fat and muscle 
go first, and subsequently skin, liver, bone, heart, and central nervous 
tissue. The surplus of nitrogenous (proteid) material absorbed by the 
gastroenteric tract leaves the body through the kidney (urea). Thus 
it is not possible to increase living tissue by simply overfeeding with proteids. 

The carbohydrates furnish the living energy of the body. A surplus 
of such foods is lost partly through an overproduction of heat, but is prin- 
cipally hoarded in the body as fat and glycogen unless oxidized and thrown 
off by exertion. It is suspected that a large quantity of water favors an 
increase of fat, but this is by no means established as a fact. 

It is difficult to establish a line of demarcation between normal and 
pathological adiposity, and clinically we speak of the latter in connection 
with certain subjective complaints, such as dyspnoea, sweating, a feeling 



K 



THE COMPONENTS OF FOOD 231 

of weakness, heart palpitation, and general anaemia. Alcohol in all forms 
(but particularly as beer and whiskey) is easily burnt up, prevents fat 
oxidation, and produces a habit of indolence. Thus for simple forms of 
fat deposit a regulation of diet and exercise is sufficient. But some people 
do not get fat by overeating, and others do not get lean by undereating. 
There must be some factor influencing metabolism outside of a lack of 
harmony between the quantity of food and the energy expended (perhaps 
suboxidation). An undue loss of proteids and fats is observed in fever, 
carcinosis, tuberculosis, anaemia, pneumonia, and acute dyspnoea, probably 
due to the formation of toxic products in such diseased conditions. The 
thyreoid gland increases fat and proteid metabolism. 

A healthy organism will thrive on plain food and assimilate the nutrient 
qualities of the crudest material. A feeble digestion will require concen- 
trated and easily digested food. A thorough knowledge of the chemistry 
of digestion and assimilation is valuable, but its practical application is 
limited, owing to the great complexity of the subject. The gastroenteric 
tract must not be likened to a test tube with a final and definite chemical 
reaction of its contents. Nature has the power of vicarious selection, and 
seeks her nutritional elements from all sources. 

The Components of Food 

Perishable, or organic, food may be divided into nitrogenous and non- 
nitrogenous. 

1. We have (a) albuminates and gelatinous substances from the animal 
and (b) gluten and legumin from the plant. 

2. We have (a) hydrocarbons, as fats, oils, butter, etc., and (b) carbo- 
hydrates, as starch, sugar, and vegetable acids. 

The final product of albumin in the gastroenteric tract is peptone. The 
transitional stages of albumin digestion by means of pepsin, hydrochloric 
acid, and pancreatic juices are designated acid albumin, hemialbumin, and 
peptones. Peptone, after reabsorption, plays its role as a tissue builder 
by the synthetic process. 

The fats are slightly changed in the stomach, but the principal assault 
upon fat takes place in the intestines by means of pancreatic juice, bile, 
and bacteria, and the final products are triglycerides, fatty acids, and 
neutral soaps. 

Absorption of fat and its components takes place in the intestines 
through epithelia, and then fat is deposited in various parts of the body. 

The Carbohydrates. — The sugars taken into the gastroenteric tract are 
in a state ready for absorption. Starchy food must be turned into absorbable 
sugar by means of dextrose, which is found in the saliva and pancreas. 
Then starch is converted into dextrin, maltose, and grape sugar, and what 
is not destroyed by fermentation in the gastroenteric tract is absorbed 
into the portal circulation. The inorganic constituents of food are the 
various salts and water. To summarize, we may say: Milk, eggs, meat, 
fowl, and fish are rich in albumin. Bread, cereals, potatoes, beans, and 
peas contain starch and albumin. Fruits, spinach, lettuce, tomatoes, 
celery, etc., supply vegetable acids, salts, sugar, etc. 



232 THE DIGESTIVE SYSTEM 

The Fuel Value of Food. — Heat and muscular power are forms of force 
and energy. The energy is developed as the food is consumed in the body. 
The unit of measurement is the calorie, this being the amount of heat 
which will raise the temperature of a pound of water 4° F. (1 kilo of water 
1°C.). 

1 gramme of protein = 4 calories. 1 lb. of protein = 1,860 calories. 

1 gramme of starch or sugar = 4 calories. 1 lb. of starch or sugar = 1,860 calories. 

1 gramme of fat = 9 calories. 1 lb. of fat = 4,220 calories. 

A man at rest requires about forty calories per kilo, of body weight. 
A man weighing sixty kilos requires two thousand calories in twenty-four 
hours. Thus, in twenty-four hours, a man requires : 

Albimiin, 50 grms. = 200 calories. 

Starch or sugar, .....' 400-500 " - 1,600 " 

Total 2,250 " 

The approximate requirement for a growing child is not found by multi- 
plying its weight in kilos by forty (calories). During the first year of its 
life a child which is thriving gains half an ounce a day and requires on an 
average a quart of milk. One quart of milk represents seven hundred calo- 
ries. In the healthy individual the normal requirements of food or heat 
energy will depend upon the amount of expenditure in motor force, mental 
force, and sexual (reproductive) force. 

CALORIES, OR HEAT UNITS, REQUIRED IN FOOD PER DAY 

{Compiled by Atwater) 

Children, to one and a half years, 767 calories. 

" two to six years, 1,418 " 

" six to fifteen years, 2,041 " 

An aged woman, 1,860 " 

An aged man, 2,477 " 

A woman at moderate work or light exercise, 2,400 " 

A man at moderate work or light exercise, 3,000 " 

A man at hard labor, 3,500 " 

One day solid food rations (Mrs. E. H. Richards): 

Bread, 16 oz 

Meat, 8 " 

Oysters, 8 " 

Cocoa, 1 " 

. Milk, 4 " 

Broth, 16 " 

Sugar, 1 " 

Butter, i " 



1,200 calories. 


243 




70 




135 




75 




613 




112 




118 





2,572 

Heat Values and Food Values. — According to Armsby the food value of 
a nutrient as a source of energy to the organism is not measured by the 



FORCE PRODUCING VALUE, OR CALORIES PER POUND 



233 



total energy which it can Uberate as heat in the body, but by the part of 
this energy which is available to the organism for physiological uses. The 
remainder of the fuel value simply serves to increase the generation of heat 
in the body, a result which may be advantageous or the reverse, according 
to the surrounding conditions. 

Atkinson's table op nutrients and calories of different people 



Proteids. 
Grms. 



Fats. 



CH. 



Total. 



Calories. 



Sewing girl, London. Wages, 93 cents a 

week 

Factory girl, Leipsic, Germany. Wages, 

$1.21 a week 

Poor laborer, Lombardy, Italy. Mostly 

vegetable diet 

Trappist monk in cloister. Little exercise. 

Vegetable diet 

German miner. Severe work 

Brickmaker, Italian, at contract work, 

Munich 

Brewery laborer, Munich. Severe work. 

Exceptional diet 

German soldier, peace footing 

German soldier, war footing 

German soldier, extraordinary exertion. 

Franco-Prussian War 

Factory operator, Massachusetts 

Private well to do family: 

Food purchased 

Food eaten 

Eastern States : 

College students boarding 

College football team 

Clubs : 

Food purchased 

Food eaten 

Teamster with hard work, Boston 

Brickmaker, Massachusetts 

U. S. Army ration 

U. S. Navy ration 



53 
52 

82 

68 
133 

187 

223 
114 
134 

157 
127 

129 
128 

138 
181 

115 
104 
254 
180 
120 
143 



33 

53 

40 

11 
113 

117 

113 
49 
58 

285 
186 

183 
177 

184 
292 

163 
136 
363 
365 
161 
184 



316 

301 

362 

469 
634 

675 

909 
480 
489 

331 
531 

467 
466 

622 
557 

480 
421 
826 
1,150 
454 
520 



402 

406 

404 

548 
880 

959 

1,245 
633 
681 

773 

844 

779 
771 

944 
1,030 

738 
661 
1,443 
1,695 
735 
847 



1,820 

1,940 

2,192 

2,304 
4,195 

4,641 

5,692 
2,798 
3,093 

4,652 
4,428 

4,146 

4,082 

4,827 
5,742 

3,874 
3,417 
7,804 
8,848 
3,851 
4,998 



As a matter of practical interest, the following calorie tables are re- 
produced (Woodruff, Garrison Rations): 



FORCE PRODUCING VALUE, OR CALORIES PER POUND 

Bacon, fat, or lard, 3,080 calories per 

Beans, 1,615 " 

Salt pork, fat, 3,510 " 

Sugar, 1,820 " 

Flour, 1,644 " 

Beef, 1,460 " 

Potatoes, raw, 375 " 

Onions, 225 " 

Oatmeal, 1,850 " 

Com meal, 1,645 " 

Tapioca or cornstarch, 1,820 " 



lb. 



234 



THE DIGESTIVE SYSTEM 



Dried apples, 1,418 calories per lb. 

Butter, 3,615 

Syrup, 1,023 

Rice, 1,630 

Canned corn, 345 

Canned tomatoes, 80 

Macaroni, 1,406 

Milk, fresh, 418 

Condensed milk, 1,595 

Peas, 1,565 

Raisins, 440 

Cheese, 1,620 

Prunes, 140 

Cabbage, ." 155 

Ham, 1,950 

Canned apricots, 460 

Barley, 1,820 

Chocolate, 2,650 

Sausage, 2,065 

Oysters, 230 

Canned salmon, 965 

Crabs, 526 

Crackers, 1,920 



For the convenience of the general practitioner, the writer herewith 

furnishes a Hst of calories compiled from many sources which may be of 

aid in selecting a rational dietary for patients and in estimating the caloric 
value of food taken or prescribed: 

Calories. 

legg, .: 80 

1 quart of milk, 675 

100 grammes of milk, 60 

100 " skimmed milk, 40 

100 " cream, 220 

100 " buttermilk, 40 

100 " ham, 400 

100 " ham and eggs, 250 

100 " wheat bread (toast), 260 

100 " zwieback, 360 

100 " sweet rice cake, 420 

100 " plain cake, 375 

100 " butter, 800 

100 " beef (raw), 120 

100 " " (roast or stewed), 220 

100 " veal cutlets, 230 

100 " '* " (raw weight), 140 

100 " chicken (raw weight), 106 

100 " squab ( " " ), 100 

100 " calves' brains, 140 

100 " fish (raw weight), 100 

100 " oysters (raw weight), 20 

100 " rice, boiled in milk, 175 

100 " mashed potatoes with butter, 127 

100 " spinach (rich), 165 

100 " puree of beans, 190 

100 " fresh beans, 40 



I 

I 



PRACTICAL DIETETICS 235 

Calories. 

100 grammes of asparagus, 20 

100 " farina, 290 

100 " omelette, 240 

100 " maccaroni, 350 

100 " caviar, 133 

100 " fruit jeUy, 90 

Physiological economy in nutrition, according to Professor R. H. 
Chittenden, means temperance and not prohibition and full freedom of 
choice in the selection of food. Food requirements vary with changing 
conditions, and the requirements of proteid food are about one half of the 
amount generally consumed. Excess means not alone waste, but unneces- 
sary strain and waste of energy to get rid of the excess. Bodily equilibrium 
requires less than 3,000 calories a day under ordinary circumstances, with 
only 16 to 18 grammes of nitrogen a day in the form of proteid. 

PRACTICAL DIETETICS 

Dieting is the systematic regulation of diet for hygienic or therapeutic 
purposes. For all practical purposes the various forms of diet will admit 
of a simple classification, viz.: 1. A liquid diet for acute febrile disease; 
2. A light diet for convalescence in febrile disease; 3. A restricted diet for 
subacute and chronic indigestion and malnutrition from whatsoever cause; 
4. A special diet, as for gout, diabetes, children, etc. 

Fluid Diet. — Selections may be made from the following lists: 

Water. — Cold, hot, aerated, flavored, toast water, sugar water, soda 
water. 

Soups. — With or without egg or cereals, etc., burnt flour soup (excellent 
in diarrhoeas), slimy soup of oatmeal or barley with and without egg, may 
be seasoned with celery salt. Bouillon, beef tea, meat juice, clam broth, 
oyster juice, mutton broth, and chicken broth have low nutritional value 
unless they contain cereals, rice, barley, sago, or eggs. 

Gruels. — Arrowroot, barley, cracker, diabetic, farina, Indian meal, 
oatmeal, rice, rice creamed, gruels dextrinized, gruels peptonized. 

Milk. — Raw, plain, with salt, with lime water, with Vichy, sterilized. 
Pasteurized, peptonized, buttermilk, kumyss, matzoon, kefir, whey, eggnog, 
white of egg in water, milk punch, malted milk. 

Milk Cure. — An exclusive diet of milk or diluted milk may be desirable 
in the following conditions or diseases: In infancy for the first eight 
months; in typhoid fever in the absence of tympanites; in acute and 
sometimes in chronic Bright 's disease; in acute pyelitis; in chronic gastric 
catarrh; in gastric ulcer and carcinoma; in neurasthenia; in scarlatina; in 
the Weir Mitchell rest cure. 

Other articles of fluid diet are gum arable solution (in water) , chocolate, 
cocoa, digestible cocoa, ice cream, water ices, Roman punch, scraped ice, 
orange juice, pineapple juice, unfermented grape juice, non-alcoholic malt 
liquors, liquid peptonoids. 

Light, or soft, diet (convalescent diet) embraces liquid diet plus meat, 
jelly, and calves' foot jelly; eggs, scrambled, soft boiled, poached, raw; 
scraped meat or beef; oysters, raw, stewed; tomato ketchup; green salads, 



236 THE DIGESTIVE SYSTEM 

with vinegar or lemon juice dressing; lettuce; watercresses ; asparagus tips; 
crackers; toast; zwieback; Albert biscuits; sponge cake; Graham crackers; 
saltines; bread (not fresh); rolls; puddings: rice, farina, cornstarch, tapioca, 
custard; purees and bisques: asparagus, bean, celery, chicken, clam, onion, 
oyster, pea, tomato; jellies: beef aspic, chicken aspic, calves' foot, orange, 
sherry, champagne, lemon, wine, cranberry; stewed fruit; stewed prunes, 
baked apples, apple sauce; oranges, grape fruit; stewed tomatoes, spinach, 
rhubarb; preserves, currant jelly, fruit jelly; Charlotte russe, blanc mange; 
oyster cocktail, egg souffle; chocolate in cakes; ham (raw), tongue, ham and 
egg omelette; calves' brains, sweetbreads; mock turtle soup; macaroni 
with tomato sauce; anchovy paste or caviar on toast; malt preparations. 

Full diet with certain restrictions embraces soft and liquid diet plus 
boiled fish, beef, mutton, and lamb stews, pot roast, broiled chicken, 
turkey, squab, venison, partridge, quail, tongue, hash, pickles (salt), corned 
beef, cauliflower, beets, asparagus, celery, potato salad, potatoes boiled 
in "jackets " and creamed, salt sardelles, anchovies, soused mackerel, 
creamed codfish, omelette, salmon, herring and herring salad, fillet of beef, 
cold meats, beefsteak, veal cutlets, capon, meat balls, meat dumplings 
with sardelle dressing, cheese (Roquefort, cream, imperial, Camembert); 
sandwiches: celery, lettuce, water cress, chicken, scraped beef, club, 
raw Westphalian ham, caviar, salt sardelles, vrith special restrictions when 
called for. 

Fever Diet for Adults and Older Children. — Beef broth and egg, mutton 
broth and egg, sago, eggnog, white of egg in water, soups, gruels, milk, 
malted milk, matzoon, kumyss, cocoa, tropon in peppermint tea, ice cream, 
water ices, custard, orange and pineapple juice, beef jelly, ginger ale. 

To these may be added in the convalescent stage : Apple sauce, baked 
apple, sponge cake, biscuits, rice, farina, bread pudding, cereals, scraped 
meat, scrambled eggs, or calves' foot jelly. 

Alcohol in the shape of whiskey, champagne, or Tokay wine is some- 
times of great value as a food and stimulant. Other articles may be selected 
from the list of liquid and soft diet. 

Fever diet for breast and bottle babies is discussed in the chapter on 
General Therapeutics and in that on Pasdiatrics. 

Stimulants and Beverages 

Alcoholic Drinks. — Alcohol as a beverage is unnecessary in young and 
healthy individuals. Persons in danger of the alcohol habit by inheritance 
should shun it. The abuse of alcoholic stimulation is invariably injurious. 
The temporary use of alcohol in certain diseases, in septic fevers in adults 
and in children, is of value and may become necessary to prolong life in 
connection with other stimulants. Given under the proper conditions 
and in proper amount, alcohol is capable of stimulating respiration, cir- 
culation, and digestion, and to a certain degree also of serving the purposes 
of a food and of supplying a certain amount of heat. It is particularly 
useful in senile loss of appetite. 

Malt Liquors. — Nutritious non-alcoholic malt liquors are obtainable 
under various names in the shops. 



STIMULANTS AND BEVERAGES 237 

Beer contains bitter extract, sugar, and from 3 to 8 per cent of 
alcohol. 

Ale, porter, and barley wine contain from 3 to 7 per cent of alco- 
hol. Beer, ale, and porter are sometimes useful in insomnia. 

Wines. — White, Rhine, and Moselle contain from 9 to 12 per cent of 
alcohol. Convalescents may require a glass of light wine with a meal. 

Red wines contain from 9 to 10 per cent of alcohol and ^ per cent 
of tannin. Wines contain sugar, alcohol, and organic acids. French, 
Hungarian, and Rhine or Moselle wines may be taken after a meal in ano- 
rexia. Excellent American wines are now obtainable for half the price of 
the imported. 

Heavy Wines.— Sherry, Port, Madeira, Tokay, and Malaga are sweet 
wines. 

Aromatic Wines. — Bordeaux, Burgundy. 

Sparkling, or champagnes, contain from 12 to 14 per cent of alcohol. 
They are serviceable in prostration and collapse with vomiting. 

Non-alcoholic Drinks. — Tea, green and black, coffee. Stimulating to the 
nervous system. If tea and coffee produce nervousness, substitute cereal 
coffee, postum coffee, malt coffee. Cocoa, chocolate, kola cocoa (digestible 
cocoa is slightly stimulating and decidedly nutritious). Pure water, lemon- 
ade made with lime juice or lemon juice, ginger ale, peppermint tea, 
toast water, soda water will quench thirst. Hot water will often quench 
thirst better than ice water. Sucking a prune will also quench thirst. Milk 
is a drink and a food at the same time, and, on account of its impor- 
tance, will be discussed in a separate chapter (Facts about Milk). 

Mineral Waters. — Mineral waters may be divided into six principal 
groups: 

1. Still and Sparkling Alkaline Waters. — Vichy, Rhenser, Apol- 
linaris, Salzbrunn, Vals, Ems, Neuenahr, Fachingen, etc. Indications : 
Gout, acid dyspepsia, chronic gastrointestinal catarrh, gravel, cystitis, 
hepatic congestion. 

2. Sulphur Waters, Cold and Hot. — Baden in Switzerland; Aix les 
Bains, St. Honore, France; Neuendorf, Weilbach, Germany; Harrowgate, 
England; White Sulphur Springs, Ohio; Richfield Springs, Sharon Springs, 
New York; White and Red Sulphur Springs, Virginia; Banft, Canada; Glen- 
wood Springs^ Colorado. Indications : Chronic articular, cutaneous, respir- 
atory, and gouty ailments. 

3. Saline Waters. — Saratoga waters, New York; Middlewich, Leam- 
ington, Cheltenham, England; Kissingen, Homburg (cold and warm), Pyr- 
mont, Kreuznach, Wiesbaden, Baden Baden (hot salt), Reichenhall, 
Nauheim (gaseous salt) , Germany. Indications : Gastric, circulatory, and 
respiratory disturbances. 

4. Indifferent Waters. — Wildbad, Gastein, Ragatz; Schlangenbad, 
Badenweiler. 

5. Chalybeate Waters. — Schwalbach, Spa, Saratoga. Indications: 
Anaemic conditions. 

6. Laxative Waters. — Carlsbad, Marienbad, Tarasp, Saratoga laxative 
waters. Indications : Hepatic and gastrointestinal disorders, obesity. 

They are valuable in a measure in the management of divers troubles, 



238 THE DIGESTIVE SYSTEM 

but the wonderful cures which they are supposed to effect are due to a 
combination of diet, exercise, and freedom from business and other worry, 
particularly in those instances in which the sufferer or alleged sufferer goes 
abroad and distance lends enchantment to the scene. 



Predigested Food 

Pancreatized food is sometimes serviceable when the digestive power is 
feeble, but is frequently ordered unnecessarily and in cases in which it is 
harmful. It is prepared by means of pepsin and hydrochloric acid or with 
extract of pancreas. The extract of pancreas is prepared by macerating 
for one week the pancreas of a pig, calf, or sheep with four times its weight 
of 50 per cent alcohol, and filtering. Peptonized food does not keep well 
and must be prepared several times a day. Beef or sarcopeptones are 
obtainable in the shops in a liquid or semisolid form, and can be made 
fresh by treatment of beef with the above mentioned extract of pancreas. 

Peptonized beef tea is made by adding ten grains of bicarbonate of 
sodium to a pound of lean beef and one pint of water. Allow to simmer 
for an hour. Mash the undissolved meat to a pulp, add a teaspoonful of 
extract of pancreas to the beef tea and pulp, and keep warm for two hours. 
Then boil for three minutes, strain, and season with salt or celery salt. 

Pancreatized milk is readily prepared by means of peptogenic powder, 
which is obtainable in the shops (see Facts about Milk). It comes in glass 
tubes with full directions on each. It may be given to children in malnu- 
trition and feebleness of digestion during acute and subacute illness, but is 
only a temporary makeshift, as its prolonged use will result in a putrid 
condition of the gastroenteric tract. 

Concentrated Foods 

In malnutrition and feeble digestion the administration of concen- 
trated food may be necessary. 

Beef meal is said to contain 77 per cent of proteids and 13 per cent of 
fat. It is tasteless and odorless. 

Soluble beef jelly is said to contain 50 per cent of proteids. It has a 
pleasant taste and odor, is nutritious, and may be added to consomme, 
broth, and gruel. 

Soluble beef and vigoral are said to contain from 50 to 60 per cent of 
proteids. They are very nutritious and palatable. 

Extract of beef, meat juice, and beef tea have little food value, but are 
slightly stimulating. A raw egg beaten up with beef tea will greatly enhance 
its value. 

Tropon, somatose, and plasmon are concentrated vegetable proteids. 
Tropon is not soluble in water, but can be taken in soup, tea, cocoa, or 
mush, also combined with iron (iron tropon). Somatose is soluble in water 
and can be used for nutrient enemas in wasting disease, etc. Condensed 
milk and evaporated cream rightly belong to the class of concentrated foods, 
but are discussed in the chapter on Milk. 



SYSTEMS OF DIET 



239 



Systems of Diet 

Banting and Ebstein Systems. — These systems of diet may be com- 
pared as follows: 





Proteids. 


Fat. 


Carbo- 
hydrates. 


Total in 
24 hrs. 


Calories. 


Banting, 


Grammes, 171 
102 


8 

85 


75 

47 


254 
234 


1,085 
1,400 


Ebstein, 



In the Banting system starch, sugar, and fluids are forbidden. The 
bulk is made up by fruit and vegetables. In the Ebstein system fat is 
allowed, and this diminishes the appetite and craving for food. Sugar and 
starch are forbidden except three and a half ounces. Fluids are restricted. 

Breakfast. — Cup of tea without sugar or milk, bread or toast with 
two oz. of butter. 

Dinner. — Soup, 4 to 6 oz. of meat, vegetables, salad, fruit, and black tea. 

Supper. — Tea, egg, fish, ham, cold meat, buttered toast, fruit. 

Oertel and Schwenninger System : 





Proteids. 


Fat. 


Carbo- 
hydrates. 


1. Maximum allowance, grammes, 


150 
250 


50 
25 


200 


2 '( <( <( 


100 







and withhold fluids. No fluids at meals. Climbing of graded paths, mas- 
sage, baths. 

In the foregoing table No. 1 is for cases where there is fat accumulation 
without much respiratory and circulatory disturbance; and No. 2 where 
there is fat accumulation with respiratory and circulatory disturbance. 

The caloric value of twenty-four hours' food in Banting's system is 
about 1,100; in Ebstein 's, about 1,400; in Oertel and Schwenninger's, about 
2,000. 

Weir Mitchell System. — Rest, passive exercise, massage twice a day, 
and Swedish movements. Skim milk diet, gradually introduced until 
patient lives entirely on milk. Vary the monotony with beef, chicken, 
and oyster soup. In six weeks' time fat is reduced. 

Diet for Leanness. — First ascertain the cause. Give sugars and starch. 
Freedom from mental strain. Abundant sleep and rest. 

Diet for Obesity. — In a diet for obesity it is practically unimportant what 
is given, so long as the nutritive value is calculated. From a study of the 
food values as shown in the preceding pages, the actual value of the various 
diet systems will readily be understood; and this will enable the practitioner 
to intelligently regulate the diet of any individual case in which he may be 
interested. 



240 



THE DIGESTIVE SYSTEM 



VEGETARIANISM 

From a study of the following menu ^ it will be seen that the dietary is 
made up of a proper variety of proteids, carbohydrates, and fats, and is 
calculated to exert a favorable influence on overfed individuals. The 
beneficial effects of vegetarianism do not depend upon the fact of its fol- 
lowers not taking animal food, but on their giving up former bad habits. 



A VEGETARIAN MENU 



DINNER 



Soups 

Cream of Peas Fruit 

Entrees 

Broiled Nuttolene — Tomato Sauce 

Sliced Savory Protoso 

Nut Roast with Potatoes 

Reushes and Salads 

Celery Apple and Banana 

Vegetables 

Sliced Tomatoes Stewed Navy Beans 

Green Corn Potatoes 

Dextrinized Grains 

Toasted Whole-wheat Wafers 

Granose Flakes Granola Porridge 

Granut Zwieback Roasted Rice 

Browned Granose Biscuits 

Granola Dry Gluten 

Toasted Wheat Flakes 

Cereals 
Farinose — Grape Sauce 

Granola Porridge — Raisins 

Liquid Foods and Beverages 

Vegetable Broth Caramel-Cereal 

Gluten Gruel Grape Gruel Dairy Cream 

Sterilized Dairy Milk Almond Cream 

Fermented Breads 

Coarse Graham Bread Fine Graham Bread 

White Bread 



Unfermented Breads 

Beaten Biscuits 

Graham Crackers Passover Bread 

Crisps 

Cooked Fruits 
Prunes Peaches Strawberries 

Fresh Fruits 
Plums Peaches Cantaloupe 

Desserts 



SheUed Walnuts 



Bread Pudding 



ARTICLES SERVED TO ORDER 

Carbon Crackers Gluten Biscuit No. 1 

Gluten Wafers Dyspeptic Wafers 

Popped Corn 

Vegetable Bouillon 

Junket Buttermilk Kumyss Kumyzoon 

Milk with Lime Water 

Tomato Sauce Stewed Tomatoes 

Com Pulp Granose Balls Protose Patties 

Floated Eggs Eggnog 

Green Peas Bean Pur6e Pease Pur^ 

Milk Custard Prune Marmalade 

Malted Foods 

Malt Honey Maltol Malted Nuts 

Sanitas Food Bromose 



EXERCISE AND DIGESTION 

Children's digestion suffers but little by active romping after a meal. 
Adults do not respond favorably to violent exercise after eating. Muscular 
fatigue and overexertion immediately before eating are not desirable. 
Dyspeptics should lie down for half an hour before eating. Aged people 
can take a short rest of half an hour after dinner. After eating a heavy 
meal, one should wait two hours before going to bed. 

Hunger produces wakefulness. Take crackers, beer, milk, and toddy. 



* Battle Creek Sanitarium. 



TOBACCO, FOOD AND DIGESTION 241 

In old age the circulatory and nervous systems are less active, the 
digestive power is less vigorous, and there is not so much demand for fuel 
in the body. Diminish the total quantity of food, give food in small 
amounts at frequent intervals, give easily digestible food, and live moderately 
and thereby prolong life. 

TOBACCO, FOOD, AND DIGESTION 

No definite rules can be formulated for the use of tobacco in relation 
to meals. Persons who are not made nervous or irritable by smoking after 
eating may do so if they enjoy it. Mild tobacco favors peristalsis and 
sometimes overcomes fatigue. Smoking before meals often destroys the 
appetite and interferes with digestion. Tobacco in its relation to diseased 
conditions will be discussed under various headings. 

Rectal alimentation and feeding by tube are discussed in the chapter on 
General Therapeutics. 



17 



CHAPTER V 
THE DIGESTIVE SYSTEM— Continued 

DISEASES OF THE MOUTH 

Synopsis: Gleneral Remarks. — Slobbering. — Dryness of Mouth. — Gingivitis. — Bleeding 
and Spongy Gums. — Stomatitis (all forms). — Noma. — Urticaria of Mouth. — Actino- 
mycosis. — Foul Tongue and Breath. — Glossitis. — Benign and Malignant Ulceration of 
Tongue. — Herpes of the Tongue. — Swollen Papilla^. — Cyst and Concrements. — Ranula. 
— Herpes. — -Eczema. — ^Fissures of the Lips. — Care of the Teeth. — Emergency Treat- 
ment of Toothache. 

GENERAL REMARKS 

A CLEAN mouth is one of the best prophylactics against disease, and is 
consequently of very great importance to the individual. The mouth is 
not only frequently the seat of purely local disease, but is prominently a 
favorable portal of entrance for microbial and putrid products which are 
known to be factors in the production of most profound constitutional 
disturbances. 

It will readily be understood that in persons afflicted with chronic 
ailments in most instances the mucous membranes have lost their integrity 
in consequence of malnutrition, and consequently offer but slight resistance 
to microbial invasion. Thus are explained the many and often fatal com- 
plications arising in the course of subacute and chronic disease. In the 
course of acute infectious fevers less saliva is secreted, the mouth becomes 
dry and hot, and in this manner local infection and invasion are favored. 
Patients suffering from stomatitis or putrid mouth swallow much septic 
material and readily infect the gastroenteric tract. Certain forms of sto- 
matitis should be looked upon as eliminative phenomena^ in which the 
bacterial character of the lesions plays a secondary role, in which local 
treatment of the mucous membrane must be combined with the best 
hygienic management in order to get satisfactory results. As a prophy- 
lactic measure, kissing of children on the mouth must be forbidden, as 
this habit obviously enough is a prolific means of disseminating infectious 
and contagious disease. Carious teeth must be extracted or filled. In the 
case of children with temporary teeth a cement filling may be inserted. 
Children and grown persons should seek to live in the best possible hygienic 
surroundings and sleep in cool rooms with windows open, encouraging con- 
stant ventilation. Sunshine, fresh air, and plain, nourishing food are the 

* Elimination as an etiological Factor of Diseases of the Alimentary Canal. By Dr. 
F. Forchheimer, of Cincinnati (Transactions of the American Pcbc'. Soc, 1896). 
242 



' BLEEDING GUMS, STOMATITIS 243 

best medicaments, riegarded from the standpoint of prophylaxis, and mouth 
washes and gargles are of great value. 

Regarding the classification of disorders of the mouth it may be stated 
that attempts have been made at nomenclature based on the microbes 
found in various inflammatory diseases of the mouth. For practical pur- 
poses, we may consider in this chapter the clinical forms met with. in prac- 
tice, from the simple inflammatory type to those of more severe and destruc- 
tive nature. For diseases peculiar to infancy and childhood, see Paediatrics. 

DISEASES OF THE MOUTH 

..Slobbering. — This manifestation, which is aptly enough described by 
the name accorded it, is not of infrequent occurrence in early infancy and 
during the period of dentition. Though frequently ascribed to local irrita- 
tion, difficult dentition, and uncleanliness, it is not necessarily so caused; 
and presents no special pathological features. In adults it is often associ- 
ated with other depraved habits, also in idiots, epileptics, and those morally 
and physically degenerate. 

Dryness of the Mouth ; Arrest of Salivary and Buccal Secretion (Xero- 
stomia). — This condition is often annoying and of sufficient clinical signifi- 
cance to call for treatment. Glycerin and rose water, equal parts, used as 
a mouth wash, will alleviate the trouble. When it occurs in febrile disease 
and in mumps water should be copiously administered. 

Gingivitis. — This acute inflammatory condition of the gums is occasioned 
by the presence of decayed teeth, retained, decomposing secretions, or local 
infection. In impaired general health and lowered vitality the gums are 
quite apt to take on this inflammatory disorder. The gums are painful 
and injected and bleed readily, and the treatment must be directed to re- 
moving the local cause (e. g., decayed teeth must be filled or extracted). 
Astringent mouth washes will accomplish much to allay and cure the affec- 
tion. Tincture of myrrh and tincture of rhatany, equal parts, applied with 
a cotton pledget along the affected gum area, are very efficacious. Tannate 
of glycerin in water as a mouth wash, and chlorate of potassium administered 
internally and used as a wash, are most efficacious remedies. Permanganate 
of potassium in water (rose colored solution), used frequently as a gargle, 
will accomplish much in the way of cleansing the mouth of decomposing 
material by its oxidizing power. 

Bleeding of the Gums, Spongy Gums, Discoloration of the Gums. — In- 
dependent of the acute inflammatory affections of the gums, bleeding is 
observed in persons of feeble health and as a prominent symptom of 
scurvy, the slightest touch frequently being sufficient to provoke bleeding. 
When the bleeding does not respond to the simple methods, prolonged 
pressure over the part with pledgets of cotton saturated with alum solution 
or persulphate of iron may favor cessation of the bleeding. Antipyrin in 
10 per cent watery solution, applied locally, also has hsemostatic proper- 
ties and may be of service. Suprarenal preparations in solution will in 
many instances prove very efficacious. Means adapted to the improve- 
ment of the general health must be employed in addition. When the 
sponginess and bleeding may be attributed to the abuse or prolonged use 
of mercurials (red line gums) and lead preparations (plumbism, blue line 



244 THE DIGESTIVE SYSTEM 

gums) , the administration of these drugs must jpro tempore be discontinued. 
The treatment of haemorrhagic gums in scurvy is described under Scurvy. 

Stomatitis Catarrhalis (Simple or Erythematous). — This form of inflam- 
mation is usually of mild type, runs an acute course, terminating in about 
a week, and is associated with no pronounced constitutional disturbances. 
It is generally observed during infancy and is caused by the introduction of 
irritating and unclean substances into the mouth (e. g., dirty fingers, unclean 
nipples). It may be concomitant with or secondary to the exanthemata 
and gastrointestinal affections. 

The SYMPTOMS are mild ; there is some rise in temperature, and the mouth 
at first is red, dry, and hot. Thirst, pain, and irritability are present; 
later the mouth becomes moist and there is increased salivation. The 
changes in the mucous membrane consist simply of local hyperemia, in- 
creased epithelial proliferation, and subsequent desquamation with little 
or no tendency to ulceration. 

The TREATMENT of this affection consists in keeping the mouth clean. 
Care is to be taken that the nipples and fingers are rendered clean before 
being introduced into the mouth. The mouth may be cleansed with 
sterile water or mild boric acid solution (2 per cent) or a mild solution of 
borax in water and glycerine. Should constipation exist, a mild laxative 
may be exhibited. 

Stomatitis Follicularis (Aphthous or Vesicular Form). — This is of severer 
type and longer duration than the simple catarrhal form. The local tissue 
changes are more marked and the constitutional disturbance more pro- 
nounced. Causative agents are any of the severer constitutional diseases, 
a deteriorated state of health, malnutrition, and unhygienic conditions and 
surroundings. The changes observed in the mucous membrane consist 
in the appearance of vesicles which ulcerate and have shallow, well defined 
grayish yellow denuded surfaces which later heal. The affection is in many 
instances so painful that the child refuses nourishment. 

Treatment. — A pale rose colored solution of permanganate of potassium 
is an efficacious mouth wash. It is best applied by swabbing the mouth 
frequently with cotton pledgets moistened with the solution. Boric acid, 
six parts, salicylic acid, one part, water, five hundred parts, make an 
excellent wash. Among other agents which may be employed are alum 
water (a teaspoonful to half a pint) or tannic acid (one drachm, glycerine, 
one ounce), thirty drops to a wineglassful of water, also Labarraque's 
solution, in water of the strength of one in twenty. 

Stomatitis Ulcerosa. — In this form destructive tissue changes are still 
more marked than in the foregoing affections. Tissues adjacent to the 
ulcerated areas are hard and infiltrated. The gums are chiefly the seat of 
the ulcerating process, and there is much puffiness and swelling and bleeding 
of the affected gums. There is, moreover, a decided foetid odor from the 
mouth. Besides local infection or putrid decomposition, scorbutus, saliva- 
tion induced by mercury (ptyalism), and malnutrition are causative agents. 
Children suffering from ulcerative stomatitis are decidedly sick, particularly 
the debilitated and cachectic from prolonged illness. In protracted cases, 
too, glandular swelling follows the local absorption of decomposed material 
and frequently terminates in suppuration. 



CANCRUM ORIS 245 

Treatment. — Fresh air, nutritious food, and attention to hygiene 
are important essentials. Constitutional diseases acting as causative factors 
will call for treatment. For local use, a 2 per cent solution of potassium 
chlorate in a wineglassful of water, to which thirty drops of tincture of myrrh 
and thirty drops of compound spirit of lavender may be added, will be found 
beneficial. Dilute hydrochloric acid, gtt. 2 to 5 in sugar water, may be 
administered internally to aid digestion. Two per cent boric acid solution, 
to one pint of which may be added thirty drops each of formalin and 
spirit of wintergreen, is a useful mouth wash. Weak solutions of peroxide 
of hydrogen or alum, a teaspoonful to half a pint of water, are also ser- 
viceable. 

For bleeding gums a saturated alum solution, suprarenal capsule solution, 
or 10 per cent antipyrine solution, locally applied, will frequently prove 
very effective and has given satisfactory results even in the case of bleeders. 
Still, instances will occur where one will be compelled to resort to the actual 
cautery (Paquelin) to check the bleeding. There are also graver cases. 
For example, in diabetes, nephritis, and chronic hepatitis with jaundice, 
patients may bleed from the gums for days; and moribund patients may 
bleed even up to the time of death, notwithstanding the best of attention 
and efforts to check the bleeding. 

Stomatitis Gangraenosa (Noma, Cancrum Oris), is of rare occurrence 
and is characterized by a rapid gangrenous destruction of tissue involving 
the neighboring structures of the mouth. It is probably of microbic origin. 
Debilitating disease and bad hygienic conditions presumably act as pre- 
disposing factors. The affection is at first local, appearing as a small 
inflamed spot, rapidly becoming gangrenous, spreading, and involving 
the surrounding tissue. This destructive process, if left unchecked, attacks 
the bony structures in its vicinity, involving the cheek and whole side 
of the face. It is unlimited in its destructive progress, and unless it is 
checked sufficiently early, death ensues as a result of general sepsis, the 
lungs, heart, liver, and kidneys showing post mortem evidences of profound 
degenerative changes. 

The indications for treatment are to check, if possible, the advance of 
the destructive process, to prevent absorption and general systemic infection, 
and, further, to maintain the strength of the patient. Locally, antiseptic 
solutions are to be frequently and diligently employed. The actual cautery 
and strong escharotics must be used to remove sloughs and destroy the 
virulent process at its seat. When, however, the sloughing area is extensive, 
a radical resort to the knife is preferable, and the resulting deformity may 
later be corrected to a degree by a plastic operation. To sustain nutrition, 
the patient should receive strengthening food stuffs, beef broth, milk, eggs, 
farina, and rice; and, in addition, some tonic may be administered. Severe 
cases of noma have been favorably influenced by diphtheria antitoxine. 

Complicating pneumonia, gastrointestinal catarrh, nephritis, or sepsis 
will require special treatment directed to minimize the intensity of the 
poisonous invasion and to support general nutrition. Kiss j el's treatment 
of noma is said to give excellent results. This procedure consists of the 
following steps: The gangrenous tissues are completely removed; the affected 
surface is scraped with a sharp spoon and washed with hot solution of boric 



246 THE DIGESTIVE SYSTEM 

acid or permanganate of potassium. The ulcer is then thoroughly rubbed 
with iodoform, and a dry dressing is applied. If all the gangrenous tissue 
cannot be removed at once, the ulcer is rubbed with iodoform and covered 
with small pieces of gauze soaked in a 1 to 1,000 solution of potassium 
permanganate. The scraping is repeated on the following day, and the 
procedure is repeated until all the gangrenous tissue is removed. Then 
iodoform is rubbed into the ulcerated surface once or twice daily and the 
ulcer is washed with permanganate until it is closed by healthy granula- 
tions. Special attention is paid to the diet and to the disinfection of the 
air of the sick room. The children are forced to take nourishment by every 
possible means. 

Stomatitis Diphtheritica. — In the course of pertussis and measles not 
infrequently aphthous patches appear in the mouth and offer a suitable 
lodgement for diphtheria bacilli; the susceptible larynx may thus become 
invaded, and as a complication true diphtheritic croup may develop. Ob- 
viously instances of such complicating and serious disease forcibly impress 
us with the necessity of securing and maintaining thorough cleanliness 
of the mouth. 

Stomatitis Tuberculosa. — In the course of general tuberculosis occasion- 
ally small ulcerative patches appear in the buccal mucous membrane. The 
tendency of the ulceration is to progress. Microscopic examination of 
the scrapings for tubercle bacilli will assist in distinguishing this form of 
ulceration from the syphilitic or epitheliomatous form. Evidences of 
general tuberculosis will also aid in establishing the nature of the affection. 
The ulcerated areas may be cocainized and attacked with a curette, lactic 
acid, trichloracetic acid, chromic acid, or the actual cautery. 

Stomatitis Syphilitica. — As one of the many manifestations of syphilis, 
small patches (leukoplakia) simulating the exudates in follicular or aphthous 
tonsillitis and those occasioned by mercury are observed. The diagnosis 
is arrived at by obtaining evidence of a specific history and noting the other 
evidences (glandular enlargements, dermatitis specifica) of luetic infection. 
The affection promptly responds to antisyphilitic treatment. Mild cauteri- 
zation with nitrate of silver, gargling with chlorate of potassium solution, 
and a mouth wash of permanganate of potassium solution are valuable 
aids in the treatment. 

Stomatitis Gonorrhoica. — Though of very rare occurrence, still this affec- 
tion is met with in practice, and is characterized by the appearance of 
yellowish white patches on the tongue and hard palate. The diagnosis 
is established by microscopical examination of the exudate for gonococci. 
As associated evidences of this affection, gonorrhoeal vulvitis and ophthalmia 
may be present. The affection runs a mild, uncomplicated course, and boric 
acid solution and permanganate of potassium solution for mouth cleansing 
purpose are efficacious. 

Croupous (Membranous) Stomatitis. — Abrasions, wounds, and inflam- 
matory lesions in the mouth are frequently found to be covered with a yellow 
pseudomembrane which may be diphtheritic or non-diphtheritic. This 
occurs frequently as a complication of the eruptive fevers and whooping 
cough, and following operations on the mouth and tonsils. From the 
mouth it may spread to the nasopharynx and larynx. When it invades 



VWER OF TONGUE 247 

the latter, it may manifest itself as membranous croup. The significance 
of membranous stomatitis is underestimated in general practice. 

The TREATMENT consists in washing and spraying with non-irritating 
mouth washes. Listerine, Seller's tablets in solution, boroformahn, and 
the internal administration of from two to five drops of dilute hydrochloric 
acid in sugar water are to be recommended. A culture from the mouth 
will reveal the presence or absence of diphtheria bacilli. When they are 
present, 2,000 units of the diphtheria antitoxine should be injected in the 
usual way, in order to prevent further systemic infection. 

Urticaria of the lips, tongue, cheeks, gums, and throat and other mucous 
membrances is found in connection with skin urticaria and other angeio- 
neurotic manifestions. 

Actinomycosis of the Mouth. — The ray fungus, or Actinomyces, is the 
cause of this chronic inflammatory affection. The parasite is found in 
the pus in the shape of small yellowish granules, made up microscopically 
of threads radiating from a centre. The fungus is taken in with the food, 
but may be transmitted in other ways. The author has observed this 
disease in stable and laundry workers. When localized in the mouth, it 
first presents itself as a small granulation tumor. The surrounding con- 
nective tissue becomes infiltrated, and finally pus foci form in the indurated 
tissue. 

The TREATMENT is by incision, curettage, cauterization, and excision, 
and the internal administration of potassium iodide. 

Leptothrix buccalis is occasionally observed. (See Leptothrix of the 
Tonsil.) 

Foul tongue is occasioned by the presence of retained secretions in the 
buccal cavity or local disease of the organ itself, and most frequently is 
due to the existence of digestive disorders or systemic disease. 

Tongue Swallowing. — Asphyxia from swallowing the tongue, owing to 
its riding over and shutting off the opening of the glottis, is occasionally 
observed. The tongue is drawn back and down over the glottis b}' the 
muscles of deglutition, and the condition is due to a congenitally long or 
large tongue or a lax frenum. It calls for immediate relief. The tip of 
the tongue may be caught up by the finger, forceps, or suture, and drawn 
toward the cheek or forward whenever the danger of asphyxiation threatens. 

Diffuse Glossitis. — This inflammation is most frequently occasioned by 
traumatism or the presence of carious teeth causing irritation, or it may 
be caused by irritants or poisons locally applied. It occasionally follows 
the use of iodine or mercury. There are swelling of the tongue, salivation, 
and some fever; the affection is painful, and frequently the tongue is so 
swollen that deglutition and even respiration become embarrassed. 

The TREATMENT resolves itself into keeping the tongue clean, administer- 
ing cracked ice to allay the inflammation, and the use of fluid food. Should 
the swelling occasion alarm as to respiratory difficulty, free scarification 
should be resorted to on the dorsal surface of the organ. 

Simple Ulcer of the Tongue and Its Frenum ; Dental Ulceration ; Riga's 
Disease. — The presence of carious teeth in the mouth and prolonged friction 
of the tongue or frenum against the teeth are causes. The introduction 
of strong destructive irritants or poisons is also a factor in causing the ulcera- 



248 THE DIGESTIVE SYSTEM 

tive process. As a rule, touching the base of the ulcer with a nitrate of 
silver stick suffices after a few applications to cure. Decayed teeth which 
have acted as factors are to be extracted or filled. In the adult, ulcer of 
the tongue occurs as a result of the incessant use of a pipe, e. g., in cases in 
which the pipe stem acts as an irritant. Should the ulcer not respond 
to simple treatment as described, or become infiltrated and indurated and 
extend, we may suspect syphilis or malignant disease, and accordingly 
treat by radical surgical interference or antisyphilitic therapy. 

Syphilitic Ulceration of the Tongue. — Superficial and deep ulcers occur- 
j^ ring in the early and later stages of syphilis are frequently enough met. 
Induration, glandular enlargements, specific dermatitis, and other signs 
of syphilis serve to distinguish this form of ulceration from tuberculous or 
epitheliomatous ulceration. The microscope, too, is a most valuable aid 
in assisting in the differential diagnosis. Where the ulcer is superficial 
and not much destruction of tissue has taken place, frequent applications 
of a strong solution of permanganate of potassium will often induce healthy 
granulation. For deeper ulceration, cauterization with nitrate of silver, 
the actual cautery, and curettage are indicated. In painful ulceration 
applications of cocaine solution will afford relief. As accessory agents, 
mouth washes are to be liberally employed. Most important, however, 
is the institution of rigid constitutional treatment with large doses of iodide 
of potassium or the iodides combined with mercury. 

Tuberculous Ulceration of the Tongue. — This is not of frequent occur- 
rence, and is seen in cases in which general tuberculosis exists. There is 
nothing descriptively characteristic of the ulcerative process which may aid 
one to distinguish by the appearance, this type of ulceration from the syph- 
ilitic. There is not the associated glandular enlargement, as a rule, such as 
we find in the syphilitic form, nor is there much if any induration of the 
neighboring tissue. The tendency, as with the syphilitic or epitheliomatous 
variety, is to spread and progress. Instances are on record in which syph- 
ilitic ulcerations have been microscopically diagnosticated as tuberculous 
owing to the accidental presence of tubercle bacilli. Such ulcerations 
heal promptly under antisyphilitic treatment. Their association with the 
existing general tuberculous condition aids in arriving at a diagnosis. 

Treatment. — The treatment, locally, resolves itself chiefly into cleansing 
the ulcer and cauterizing it with nitrate of silver, and in some instances 
excision of the ulcer may be indicated. Constitutional treatment and the 
observance of the hygiene applying to general tuberculosis must of course 
be carried out. 

Epitheliomatous Ulceration of the Tongue ; Cancer of the Tongue. — This 
form, to be absolutely distinguished from other forms of ulceration, requires 
the aid of the microscope. As a rule, it occurs about middle life, and as 
contributing causative agents local irritation (carious teeth giving rise to 
dental ulcer), old scar tissue, and possibly neglected frequent superficial 
ulcerative processes may be local factors in initiating the progress. These 
forms of ulcer are generally situated on the side of the tongue, in the 
bicuspid or molar region, and have a tendency to grow rapidly, spreading 
downward toward the floor of the mouth and back into the fauces. One 
characteristic, though not diagnostic, feature is the presence of severe pain 



RANULA 249 

and much salivation. The submaxillary glands and those of the neck soon 
become indurated and enlarged. 

Treatment. — The treatment is strictly surgical, and extirpation of the 
ulcerated and surrounding area is to be resorted to when the case is seen 
early enough in its course. Where there is extension with associated glan- 
dular enlargement, extirpation of the organ is imperative, and a secondary 
operation for removal of the involved glands, submaxillary and cervical, 
is to be undertaken. Should the disease have reached such a stage that 
the case becomes unsuitable for an operation, resort must be had to palliative 
and supportive measures. Locally, frequent applications of cocaine and 
the use of morphine hypodermically will alleviate much of the patient's 
suffering and render the unfortunate state bearable. Exposure to the 
action of x rays, Finssen light, or radium salts may be tried. An operation 
should not be undertaken until after the patient has had the "benefit of 
the doubt " (i. e., by antisyphilitic treatment). 

Herpes of the tongue is occasionally met. It gives rise to considerable 
discomfort, but disappears spontaneously. An antiseptic mouth wash 
may be used. 

Swollen Papillae of the Tongue. — As a result of irritation, e. g., excessive 
or prolonged smoking, or sudden contact of the tongue with very hot or 
acid fluids, the papillae may become swollen. This condition is most fre- 
quently seen affecting the papillae near the posterior portion of the tongue, 
and it gives rise to a burning sensation in the throat. The swollen papillae 
disappear spontaneously, or may be cauterized with 5 per cent nitrate 
of silver solution. If chronically enlarged, they may be snipped off with a 
pair of scissors. 

Lymphangeioma of tongue, or cysts, or hygroma, may require the actual 
cautery. Benign tumors should be extirpated. 

Salivary Concrements. — Deposits of the contained calcium phosphate 
or magnesium salts from salivary secretions are occasionally found in the 
crypts and folds and at the orifices of the muciparous follicles of the buccal 
cavity, and frequently appear spontaneously in the secretions from the 
mouth; or, where large and in view, may be expressed by means of a forceps 
or small spoon. 

Ranula. — This condition is the result of occlusion of one or several 
mucous ducts resulting in cystic formation, and it is most frequently seen 
on either side of the tongue in the floor of the mouth, protruding and pre- 
senting a shining, slightly bluish surface. In many instances profuse 
salivation is present, and where the cyst is rendered very tense by its fluid 
contents, pain is an additional symptom. 

The TREATMENT is to incisc and remove as liberal a piece of the sac as 
possible, and to avoid coaptation of the edges of the wound, and thus prevent 
adherence of edges of wound and refilling of the sac. In addition, the edges 
and cavity of the attacked area may be swabbed with a solution of nitrate 
of silver to encourage healing. 

Herpes of the Lips. — In the course of acute febrile diseases, such as colds, 
pneumonia, typhoid fever, measles, and scarlet fever, herpetic areas develop 
on the lips, slightly involving the cutaneous area. The vesicles are painful 
and have a tendency to dry in from a few days to a week. As a rule there 



250 THE DIGESTIVE SYSTEM 

is no spontaneous rupture, and in the treatment the object is to encourage 
drying of the vesicle, so that the resulting crusts may become less a source 
of irritation than where attempts at rupture have been instituted. Camphor 
ice acts admirably as a soothing application. 

Perlesche usually starts as a small crack, or fissure, at the angle of the 
mouth, and in consequence of irritation, licking with the tongue, and sub- 
sequent addition of infectious material, it spreads in breadth and depth, 
assuming an ulcerous character, and is covered with a grayish exudate. 

The TREATMENT consists in cleansing the site and touching the fissure 
or ulcer area with nitrate of silver and protecting with a soothing ointment 
(camphor ice). 

Eczema of the Lips. — This frequent affection attacks the border of the 
lips, involving the median portion and spreading toward the angle of the 
mouth. Many minute cracks and fissures are present, and the painful 
surface bleeds readily. Local applications of mild ointments, such as boric 
acid with vaseline (10 per cent), or mild zinc oxide ointment with lanolin, 
will assist in hastening the healing process. 

Cracks and Fissures of the Lips. — Local irritation, exposure to cold, 
and contact of the lips with acrid substances are exciting causes of this 
condition, which simulates eczema of the lips very much. Camphor ice 
applied diligently will remedy the condition, and where the fissures become 
deep, touching with nitrate of silver stick after stretching the lips will suffice 
to cure. 

Foul Breath. — Independently of acute or chronic digestive disorders 
or diseases, we frequently observe a foul breath as an evidence of retained 
secretions behind the plica tonsillaris, also as the result of dental caries, 
nasal catarrh, and oesophageal and respiratory diseases. To combat the 
symptom, independently of the causative factors, antiseptic gargles are 
indicated. Where the causative factors can be attacked mechanically, 
they should be removed. Foetor ex ore is rarely due to chemical changes 
in the salivary secretion. 

Sordes. — In febrile and debilitating disease the lips are frequently 
coated with a brown mixture of food remnants, epithelial debris, and micro- 
organisms, for which frequent washing and the application of camphor ice 
are indicated. 

THE CARE OF THE TEETH 

By William Caille, D.D.S. 

The value of a good set of teeth is not to be computed, if only the service 
of dividing and masticating the food is considered, mastication being the 
first step in a series of processes by which the food is transformed into 
nourishment adapted to the needs of the system. When to this considera- 
tion we add their importance in assisting vocalization — distinctness of utter- 
ance in speech and song — and also when we consider the intimate relation 
that exists between the innervation of the organ of hearing and the dental 
apparatus, it can easily be understood that any pathological condition 
in the one may cause symptoms referable to the other. As we know, the 
sensory innervation of the ear is derived from the fifth, or trigeminal, nerve; 



CARE AND TREATMENT OF THE TEMPORARY SET OF TEETH 251 

this nerve, through the superior and inferior maxillary branches, is the 
sensory nerve of the teeth. 

Thus dental caries is often the cause of severe reflex symptoms more 
or less remote — such as "otalgia " (pain in the ear) or a general neuralgia 
in the head. The patient is dosed with medicine for a long time without 
getting relief, and finally drifts into the hands of a dentist, who finds a 
badly decayed wisdom tooth to start with. After its extraction (if too 
far gone to fill) the pain in the ear vanishes. Treatment of all other teeth 
found to be carious finally results in a general feeling of comfort to the 
patient, with no recurrence of neuralgia. It is important to bear in mind 
at all times the possibility of refiex 

pain from an irritating tooth and also o A=irf fc_^^ 

the intimate relation between dental ^rWCy M.lM Wi\ai£\ 

much larger amount of animal matter | ^JMl^ — v I '^'^^^^^^l^i I 
than the permanent, are consequently j. ^t^otmI iST bI^^A S 
of a less dense structure, and, there- >* ^^ Wip^^ j) ^ 

fore, are more liable to rapid decay. | J 

The pulps of the deciduous teeth are "* 
relatively larger than the pulps of ^^°- ^^^• 

the permanent teeth, and when nearly 

or quite exposed by decay are more susceptible to the action of irritating 
agents and are more apt to lose their vitality under untoward influence. 
They demand more care and attention for this reason than the permanent 
teeth, especially when we consider how very important it is to preserve the 
first set until their successors are ready to appear. 

At about the fifth month after birth the process known as the eruption 
of the teeth begins. The rule is that the lower teeth precede the upper 
of the same class by two or three months. They generally appear in pairs. 
The usual order of their eruption is as follows : 

Upper set — ^Two central incisors, between the fifth and eighth months. Two lateral 
incisors, between the seventh and tenth months. Two canines, between the twelfth and 
sixteenth months. Two first molars, between the fourteenth and twentieth months. 
Two second molars, between the twentieth and thirty-sixth months. 

The lower set consists of the same number of teeth, known by the same 
names. It must not be forgotten that the eruption of the second set begins 
before any of the first teeth are shed. Thus, between the fifth and sixth 
years the first permanent molars, four in number, one on each side of the 
upper and lower jaw, make their appearance. These are generally sup- 
posed by parents to belong to the first set, and, therefore, if they are found 
decayed shortly after their eruption, no attention is paid to them, because 
it is thought they will soon have to make room for their successors, and 
before the error is discovered the mischief is irreparable. 



252 



THE DIGESTIVE SYSTEM 



For reasons not fully understood, a great liability exists in the sixth year 
molar to deep fissure formation, with imperfect union of the enamel edges, 
and from this and other causes we recognize a special tendency to caries; 

in fact, these teeth are fre- 
quently decayed before they 
are fully protruded. This fact 
shows the importance of extra 
care and more prompt atten- 
tion to them, for if they can be 
preserved until they become 
thoroughly solidified, their 
proneness to decay is very 
much lessened, and the chances 
of retaining them throughout 
life are correspondingly in- 
creased. The six year molars 
are the largest teeth in the 
mouth, consequently they are 
very important as masticators. 
The want of a proper appre- 
ciation and proper treatment 
of these six year molars is one 
of the most fruitful causes of 
the defective masticating apparatus of a vast majority of people at and 
beyond forty years of age. 




Fig. 104. — At six vears. 



Shedding of the Temporary and Eruption of the Permanent Set 

When the small size and delicate structure of the jaws of an infant, 
and the fact that the teeth correspond to them in size, are considered, it 
will be apparent that the provision of a second set, large and strong in 
proportion to the increased size and strength of the adult jaw, is a necessity. 
Almost coincidently, therefore, with the development of the germ of each 
temporary tooth, and in what may be termed an appendage to the sac in 
which it is enclosed, appears the germ of its successor. While, therefore, 
the development of the temporary teeth is advancing, the germs of the 
second, or permanent, set are also progressing. When the former make 
their appearance the latter are in various stages of development. 

The second, or permanent, set of teeth are thirty-two in number, the 
sixth year molars constituting a part of this set. The following tables give 
the average time and order of eruption of the permanent teeth. 

First molar, between five and six years. Central incisors, between six and eight 
years. Lateral incisors; between seven and nine years. First bicuspids, between nine 
and ten years. Second bicuspids, between ten and eleven years. Canines, between 
eleven and thirteen years. Second molars, between twelve and fourteen years. Wisdom 
teeth, between seventeen and twenty-one years. 

The period included between the sixth and the fourteenth years of the child's 
life is an exceptionally important one with reference to the care of the teeth, 
their subsequent condition for life depending largely upon the treatment 



SHEDDING OF TEMPORARY AND ERUPTION OP PERMANENT SET 253 



during this period. This attention on the part of the parent or guardian 
should consist, not only in advising or directing the habitual thorough 
cleansing of the teeth of the child, but should include a personal supervision 
of the operation, in order that serious omissions as to time or manner may 
not occur. In addition, a systematic examination of the mouth by a com- 
petent dentist should be made at frequent intervals. Teeth become carious 
from constitutional as well as local causes. 

The difference between individuals in the physical character of the 
teeth (differences in their organization, ossification, and density, and con- 
sequently in their healthfulness, usefulness, and durability) are generally 
in harmony with other constitutional peculiarities. The size, shape, and 
structure of the teeth indicate also their liability to decay or their power 
of resistance to unfavorable conditions. The character and progress of 
decay vary also in the several temperaments not less than does the orig- 
inal structure — liability to decay — its character and progress being, how- 
ever, much modified by the state of the general health. Teeth poorly 
organized may, by reason of favorable systemic conditions and intelligent, 
•persistent care, be made to out- 
last even those of vastly su- 
perior original structure, but 
which succumb to unfavorable 
constitutional conditions or 
neglect. The temporary inter- 
ruption of nutrition by acute 
infantile diseases, such as mea- 
sles, scarlet fever, rickets, etc., 
is generally recorded distinctly 
in the dental organs. 

Teeth regular in their posi- 
tions, of large size, of a rich 
yellowish-brown color, with 
dentin as dense as ivory, and 
enamel thickly and evenly de- 
posited, represent a vigorous, 
healthy constitution, whereas 
teeth that are opaque and 
chalky, with enamel only semi- 
crystallized, deficient in quantity, and irregularly deposited, and the dentin 
soft or friable, represent constitutional poverty. 

The teeth are a part, and an exquisitely organized part, of the animal 
economy. They must, therefore, be more or less influenced by the state 
of the general health. 

Moreover, morbid secretions of the mouth in deranged systemic con- 
ditions tend markedly to the production of caries. Irritation of the mucous 
membrane, such as is caused by an accumulation of tartar which has insinu- 
ated itself between the gums and the necks of the teeth, will provoke a 
mucous secretion decidedly acid, and, as a consequence, destructive to 
tooth structure, also derangements of the alimentary canal are generally 
accompanied by acidity of the saliva. 




Fig. 105. — At six years. 



254 



THE DIGESTIVE SYSTEM 



Faulty articulation of the teeth very often prevents a thorough mastica- 
tion of food, also in children having a mouthful of carious teeth causing 
acute pain while eating, and forcing them to bolt their food, which soon 
results in dyspeptic troubles, and a general acid condition of the digestive 
fluids, which are regurgitated from the stomach to the mouth, acting in 
this way directly upon the teeth. 

Many cases have come to my notice in which faulty articulation could 
be traced back to mouth breathing, due to nasal obstructions, and requiring 
years of regulating to bring about a normal position of the teeth. Thumb 
sucking may in time bring on protrusion of the upper jaw, with sub- 
sequent derangement of the 
teeth. The physician can 
greatly help toward prevent- 
ing such a condition, because 
he generally is in touch with 
the patient long before the 
dentist sees him. 

As soon as the child has 
its first set of teeth, a careful 
examination of the mouth 
should be made by a compe- 
tent dentist, and if any cavi- 
ties are found, they should be 
carefully treated, and gutta 
percha, cement, or amalgam 
fillings inserted. I mention 
these three kinds of fillings 
because they are easily ma- 
nipulated, and the child is 
not subjected to a long sit- 
ting. For filling children's teeth, I prefer a non-conductive material, such 
as gutta percha, on account of the supersensitive condition of the tem- 
porary set of teeth; this will necessitate seeing the child more often than 
if metal fillings were used, but it is better in the end. 

Three sittings annually are not too many at this period of the child's 
life, owing to the fact that deciduous teeth easily crumble and break away, 
and thereby lose the fillings. Parents should teach their children how to 
use a mouth wash and handle a tooth brush ; the child will never forget the 
importance of this in later years if it is instructed early in life. 

The importance of keeping the child's mouth thoroughly clean at all 
times cannot be emphasized sufficiently. The mouth and nasopharynx 
are the portal of entrance for many infectious diseases, and a filthy mouth 
favors infection. 

Cleaning the Teeth 

If the teeth are properly cleaned on arising, they are freed from glutinous 
products of bacterial origin, which have vegetated during sleep, and the 
food that is taken during the day is then not likely to adhere to them; 
what food does lodge in the interdental spaces may be dislodged by the 




Fig. 106. — At eleven vears. 



I 



REMARKS ON THE EMERGENCY TREATMENT OF TOOTHACHE 255 

toothpick or floss. Any particles which remain probably do no harm in 
the few hours befoxe the bedtime cleansing, because the activities of the 
mouth during the day will hinder, if not entirely check, the growth of 
microorganisms. The bedtime cleansing will, as far as possible, remove 
fermentable matter from the mouth which has accumulated during the day. 
Brushing with a dentifrice may be supplemented with floss and an antiseptic 
and alkaline wash. 

Antiseptics for oral use should be alkaline in reaction, not merely neutral 
but distinctly alkaline. A perfect dental antiseptic, besides being alkaline, 
should not coagulate albumin. It should be a powerful non-irritating 
deodorant. 

Remarks on Pulpitis-periostitis , Alveolar Abscess, and Alveolar Pyorrhoea 

In toothache from pulpitis decomposed food acts as an irritant on the 
exposed pulp and nerve. A filling carelessly inserted and producing pressure 
on the vital part of the tooth may also cause pulpitis and ultimately the 
death of the tooth. Supersensitive teeth, into which a metal filling is 
inserted without first taking the precaution to line the cavity with some 
non-conducting material, frequently give trouble, as do metal filled teeth, 
with cavities extending almost to the pulp. Patients so afflicted complain 
of soreness and tenderness while eating and drinking. Toothache from 
pulpitis and periostitis is the most common form. Local inflammation 
may sometimes be checked by local applications, such as a hot water bag, 
a hot poultice of tea leaves, capsicum plaster applied over the dry gums, 
or equal parts of tincture of iodine and tincture of aconite applied to the 
gums by means of a brush or swab. Care should be taken not to allow the 
mixture to flow back into the mouth. After periostitis is more marked, 
the tooth may often be saved by opening up the pulp chamber. Relief 
is immediate, and subsequently the devitalized nerve may be removed and 
a general antiseptic treatment and final filling will be indicated. Alveolar 
abscess is treated by free incision, and alveolar pyorrhoea is treated by 
removing the source of irritation and by the prolonged use of antiseptic 
and astringent mouth washes. 

Remarks on the Emergency Treatment of Toothache 

The dentist is, of course, in the best position to intelligently manage 
a toothache, but for the benefit of those out of reach of a dentist the follow- 
ing advice is given: 

Clean and dry the cavity by means of absorbent cotton on a wooden 
toothpick, and insert a pledget of cotton saturated with the following 
preparation: 

I^ Orthoform, 1^ parts; 

Phenol (crystallized), 1^ parts; 

Camphor, 4 parts; 

Chloral hydrate, 4 parts. 

M. 



256 THE DIGESTIVE SYSTEM 

The cotton pledget must not be too large, allowing room for a second 
pledget of cotton saturated with sandarac varnish. Ia a few minutes the 
varnish solidifies and protects practically as a waterproof filling. This 
method is very effective when we have an exposed pulp to deal with. Validol 
camphorate can be used in the same manner with good results, and as the 
Validol does not injure the surrounding tissues, it is especially valuable 
and safe in the hands of the patient. 

Brief Remarks on the Regulation of the Teeth 

The time that is generally considered most favorable for correction is 
between the thirteenth and eighteenth years; however, the health and 
strength of the patient at the time of any proposed operation for irregularity 
is so important a consideration that it must not be disregarded. The in- 
dividual is passing from the stage of childhood into that of manhood or 
womanhood, and in this change, especially in the case of the female, the life 
forces are taxed to the utmost. At this time also the mental faculties are 
being severely strained by study, in consequence of which, if the physical 
culture of the individual is neglected, as it too often is, the nervous system 
becomes unduly exalted. To meet and partially compensate for these 
drains upon the system, it is most important that full nutrition be sustained. 
To do this with teeth that are sore or tender to the touch by reason of 
operative interference is impossible, and hence the system will be still further 
weakened by lack of nourishment if any severe operation is undertaken. 
It is, therefore, much better to postpone the operation until a time when 
the vital power can stand the strain. 

Family Type of Dental Deformity 

When any great deformity of the teeth and jaws, such as anterior pro- 
trusion of either jaw or a V-shaped arch, is shown to be hereditary, it is 
well to take into consideration the hereditary feature of the case before 
beginning any work for correction. Where the irregularity is known to 
have been acquired in the parent of the child, and thus to have been trans- 
mitted but once, the difficulties in the case are not so marked, because 
the type has scarcely been confirmed; but where it has been transmitted 
through two or more generations the impress is strong and difficult to 
overcome. In the latter case the correction of the deformity will not be 
more difficult than usual, but after correction the tendency of perverted 
nature to cause a return to the family type will be so strong as almost to 
baffle us in our attempts to preserve the advantage we have gained. 



CHAPTER VI 
THE DIGESTIVE SYSTEM— Continued 

DISEASES OF THE OESOPHAGUS 

Synopsis: Remarks. — Anomalies of the (Esophagus, Thrush, Oesophagitis, Ulcer, Cancer; 
Stricture, Sacculation, Paralysis, Rupture, Foreign Bodies in the (Esophagus. 

INTRODUCTORY REMARKS 

Function of the CEsophagus. — The function of the oesophagus is to carry- 
food by successive contractile efforts from the pharynx to the stomach. 
Food is probably carried down by the oesophagus to a point below the 
bifurcation of the trachea, from which point it is squirted into the stomach 
upon the relaxation of the cardia. This accounts for the delay of from six 
to ten seconds between the first and second swallowing sounds which are 
heard at the tip of the seventh costal cartilage on the left side. The action 
of the oesophagus is involuntary and it applies alike to both fluids and solids. 
The muscular tube is innervated by the pneumogastric nerves; hence 
diseases affecting these nerves affect the act of deglutition. 

Composition. — The wall of the tube is composed of three layers, a mus- 
cular, submucous, and mucous. The muscular coat consists of a layer of 
longitudinal and another of circular fibres. The submucous coat contains 
the mucous glands. The lining, or mucous, coat is made up of stratified 
epithelium, the superficial or innermost layer of which is squamous. The 
knowledge of this minute anatomy will explain the terminal effects of injuries 
to the tube, whether mild or severe, depending upon which coat has been 
injured. 

Position.— The position of the cesophagus is slightly to the left of the 
median plane down to the fifth dorsal vertebra, from which point it inclines 
more' to the left, ending at the cardiac orifice of the stomach. This point 
lies opposite the tip of the seventh costal cartilage, 2.5 cm. to the left of 
the sternum and about 10 cm. posterior. - Posteriorly the point of orienta- 
tion is the fifth dorsal spine, thence descending to the left of the ninth dorsal 
spine. 

ANOMALIES OF THE OESOPHAGUS 

Congenital fistula due to the failure of growth in foetal development 
between the second and third branchial arches. The opening is above and 
external to the sternoclavicular articulation. A fistulous opening com- 
municating with the trachea may exist. 

The oesophagus may be absent. 

18 257 



258 THE DIGESTIVE SYSTEM 

Obliteration of the lumen, leaving a fibrous cord to indicate the continuity 
of structure. 

Stenosis of the oesophagus may be congenital and give little or no incon- 
venience until late in life. 

Dilatations of the lumen may be congenital or may accompany stenosis, 
being situated immediately above it. Sacculations, or diverticula, may be 
congenital or may be due to a weakened wall yielding before the pressure of 
swallowing. Such formations are usually at the commencement of the 
oesophagus. Sacculations may also be due to adhesions and tension from 
without, or to cicatricial contraction within. 

Thrush of the oesophagus often accompanies thrush in the mouth in 
infants and yields to the treatment directed against this condition. 

ACUTE INFLAMMATIONS OF THE OESOPHAGUS 

Acute inflammations of the oesophagus may be due to or accompany: 

1. Acute fevers when severe as in diphtheria, pneumonia, typhoid, small- 
pox, and pyaemia. 2. Mechanical, chemical, or thermal traumatism, when 
bodies capable of inflicting such injury have been swallowed. 3. Cancerous 
inflammation involving neighboring tissues, but not having yet invaded 
the oesophagus itself. 4. Some unknown cause, hence appearing spontan- 
eously, as in sucklings, with or without ulceration. 

Symptoms. — Symptoms of inflammatory conditions are more or less 
alike and are: Pain on swallowing, especially acute. Sometimes constant 
dull pain beneath the sternum. Regurgitation may be present, if there 
is a foreign body in the oesophagus. The diagnosis of the exact condition 
will depend upon the history and examination. The use of a bougie or 
oesophagoscope is contraindicated during the acute stage. 

Treatment. — The treatment of CBSophagitis depends upon the severity 
of the condition. If it is mild or slight, no special treatment is required 
other than with soft foods or demulcent drinks. In severe cases resort to 
rectal enemata and give no food by the mouth until the acute symptoms 
have subsided. Demulcent drinks and ice by the mouth may be used to 
relieve pain. Cold may be applied externally to the neck or sternum. 
Analgetics may be a necessary addition when severe symptoms exist. 
After corrosives have been swallowed we expect cicatricial contractions 
or strictures to show themselves in from three to six months. Bougies 
should be passed before that time to prevent the narrowing of the lumen 
and the occurrence of such a complication. 

CHRONIC INFLAMMATIONS OF THE (ESOPHAGUS— ULCER AND CANCER 

Chronic inflammatory conditions of the oesophagus, with and without 
softening, may follow the acute conditions mentioned above. 

Ulcers. — Ulcers of the oesophagus may occur in cachectic conditions, 
diabetes, nephritis, hepatitis, or malignant disease, including tuberculosis. 
In chronic heart disease with disturbed portal circulation the veins of the 
lower portion of the oesophagus may be dilated, and the lining membrane 
be covered with mucus due to a chronic catarrh. If these veins ulcerate 
through, or rupture from any cause, the patient may have a severe 



ULCER, CANCER, STRICTURE, PARALYSIS, RUPTURE OF OESOPHAGUS 259 

haemorrhage, or may bleed to death without giving evidence of the haem- 
orrhage. The blood in such cases may be swallowed and retained in the 
stomach and intestines, or there may be slight haemorrhage and vomiting 
of the blood, and it will be a difficult matter to decide whether it is an 
oesophageal or a gastric haemorrhage. Again, the blood may be swallowed 
and pass per rectum and this be the only evidence of the haemorrhage. 
The use of the oesophagoscope is a help in such conditions, especially if there 
are old ulcers, but it must be used with the greatest care. 

Cancer. — Cancer of the oesophagus is usually of the epithelioma type 
and may or may not ulcerate early, due to the mechanical irritation of 
the food. 

If the growth causes much stenosis, we get a gradual dilatation of the 
tube above the tumor due to accumulation of food distending it. This food 
may later be swallowed, but is usually regurgitated. As the cancerous 
growth advances it in volves the neighboring organs and may thus per- 
forate into the trachea, pericardium, aorta, or pleura or even erode the 
vertebrae. 

Symptoms. — Cancer of the oesophagus is more frequent in men over fifty, 
and it is accompanied with progressive dysphagia, first for solids and then 
for liquids, and rapid emaciation. Regurgitation may occur early or late. 
Pain may be a constant feature or occur only after eating food. Enlarge- 
ment of the cervical glands may occur. Three conditions simulate malignant 
disease — senile dysphagia, nervous dysphagia, and an oesophageal pouch. 
Spasmodic stricture may be caused by dyspepsia. 

Diagnosis. — The diagnosis is made by the passage of the bougie and 
from the symptoms enumerated. 

Prognosis. — The prognosis is hopeless, and the usual mode of death is 
from asthenia or sudden perforation of some vital organ. 

Treatment. — The treatment is to relieve the suffering, resorting to 
morphine, codeine, and cocaine without hesitation. Analgetics dissolved 
or suspended in mucilage give relief. Gastrostomy is advisable, if done 
eaaly, before asthenia is too pronounced. The use of the x-ray or radium 
has not been successful, though one case can be vouched for by the author 
where the stricture has been relieved and life apparently prolonged after 
a course of x-ray exposures. Radium as a cancer cure has not given satis- 
factory results. In every case of malignant disease the patient should have 
the benefit of the doubt and receive antisyphilitic treatment. 

STRICTURE, PARALYSIS, RUPTURE, ETC. 

Stricture of the oesophagus may be: 

1. Congenital. 2. Due to cicatricial contraction following ulcers due 
to corrosives, syphilis, or typhoid. 3. A result of tumors, benign or malig- 
nant, in the wall, narrowing the lumen. 4. Caused by pressure from with- 
o\d, as of aneurysms, swollen lymph glands, enlarged thyreoid, pericardial 
effusion, and tumors not involving the wall itself. 

Diagnosis. — The diagnosis of the true condition will depend upon a 
close study of the history and physical signs. From the history we may 
learn of the occurrence or non-occurrence of any previous traumatism, 



260 THE DIGESTIVE SYSTEM 

or inflammatory condition, with or without a general or constitutional 
disease. The rapidity of the increasing severity of the symptoms is an 
important point. 

Symptoms. — Concomitant symptoms in other organs should be noted 
especially. If regurgitation is present, the time of its occurrence with 
respect to the ingestion of food is a fair indication of the position of the 




Fig. 107. — Introducing (Esophageal Bougie. 

stricture. Regurgitation immediately after swallowing indicates a high 
position of the stricture, but, if it is delayed, a low position. The fact that 
the food is regurgitated, and not vomited, can be discovered by the odor, 
the absence of hydrochloric acid, and the unchanged condition. Ausculta- 
tion for a delayed second swallowing sound also helps. Then, lastly, we 
may try the passing of bougies, beginning with the largest size of the olive 
tipped. Gentleness in manipulating a bougie is imperative, because of 
our ignorance of the actual condition and the possibility of rupturing the 
oesophagus and puncturing an important viscus. 



FOREIGN BODIES IN THE CESOPHAGUS 261 

Spasm or spasmodic stricture may occur in hysteria, hypochondriasis, 
chorea, epilepsy, idiocy, or hydrophobia and after irritation by foreign 
bodies. It may be a very painful condition, especially if some sharp 
body has been swallowed, and persist for a day or so, or even continue for 
weeks. The actual damage may be very trivial, but the nervous spasm 
and sensation of pain will persist. 

The treatment of such a condition is that of the general consti- 
tution. Sometimes a cure may follow the passing of a bougie, especially in 
neurotic conditions, if done with demonstrative formality. The bougie may 
or may not be arrested at the site of the stricture. Organic stricture of 
a non-malignant character requires dilatation by means of flexible bougies 
or it must be overcome by surgical means. A low down lesion can be reached 
by opening the thorax under negative pressure. 

Paralysis of the (Esophagus 

Paralysis of the oesophagus is very rare and usually of central origin, 
as in bulbar paralysis. Following diphtheria, there may be a peripheral 
paralysis. 

Prognosis. — The prognosis in the first would be hopeless, while in the 
second it would be good, unless the paralysis extended and involved some 
vital organ. 

Rupture of the (Esophagus 

Rupture of the oesophagus from violence or in the course of cancerous 
softening has a fatal termination. 

Foreign Bodies in the (Esophagus 

Foreign bodies in the cesophagus can be located by means of the bougie 
and by the use of x rays. The use of the Rontgen ray in the diagnosis of 
foreign bodies in the oesophagus is of the greatest value only when those 
bodies are metallic, as we then obtain a definite outline of them and their 
location. If the body is of some other material, we must use the greatest 
care in forming an opinion of the importance of the shadows on the plate. 
In such cases it is best to make two or more plates at intervals of some days, 
and compare them carefully. Even with the most careful comparison the 
X ray is not a positive factor in such diagnosis. One case has been recently 
recorded of an eminent surgeon who depended upon the x ray for the 
diagnosis of the position of a tooth plate said to have been swallowed by 
a patient. It was apparently located at the cardia, but when gastrotomy 
was performed nothing was found. The next day the tooth plate was 
found in a crevice of the bed. 

Fish bones and other small foreign bodies can sometimes be extracted by 
means of the bristle probang; coins and tin whistles by the coin catcher. 
When a foreign body is located and cannot be removed by such means or 
cannot be pushed into the stomach, surgical methods of removal must be 
adopted. 



CHAPTER Vn 

THE DIGESTIVE SYSTEM— Continued 

CLINICAL PATHOLOGY OF THE STOMACH AND INTESTINE 
AND DIAGNOSTIC TECHNIQUE 

Synopsis: Clinical Pathology of the Stomach, Motor Phenomena, Sensory Phenomena of 
the Stomach. — Secretory Phenomena of the Stomach.— -Hydrochloric Acid in the 
Stomach, Digestive Ferments. — Diagnostic Technique. — Transillumination with Fluo- 
rescein. — Remarks on the Clinical Pathology of the Intestine. — Motor, Sensory and 
Secretory Phenomena of the Intestines. — Diagnostic Technique. — Examination of 
Faeces. — Conclusions. 

REMARKS ON THE CLINICAL PATHOLOGY OF THE STOMACH 

A healthy stomach mechanically and chemically prepares the food 
for the intestines, and very little absorption takes place in the stomach 
proper. The normal motor function of the stomach is fairly understood. 
The fundus has a peristaltic action with little interior tension; the pyloric 
antrum has a strong muscular action with high interior pressure. A 
sphincterlike arrangement closes this segment against the fundus and permits 
the gastric contents to flow through the relaxed sphincter at the pylorus 
into the intestine. A very slow transfer of contents may be followed by 
a dilatation of the stomach and an undue formation of gas and fatty acids. 

Motor Phenomena and Neuroses 

Regurgitation and Vomiting; Singultus. — The eardia of the stomach 
will open during the act of swallowing. 

Regurgitation and eructation of gases, air, and fluids may take place 
from the oesophagus or stomach. If they are from the latter, hydrochloric 
acid and fatty acids will give an acid taste in the mouth (pyrosis, water 
brash) . 

Vomiting is due to a complex muscular action of the stomach and 
diaphragm combined. The impulse takes its origin in the medulla, near 
the respiratory centre, and may be due to local brain irritation or to a reflex 
from the abdominal vagus nerve, and the salivary glands also participate 
in the act. We speak of nervous, paroxysmal, and reflex vomiting ; cerebral 
or toxic vomiting from alcohol, apomorphine, chloroform, ether, sewer gas, 
bacterial poisons, sepsis, and uraemia. Reflex vomiting, if cerebral, is 
usually projectile and unattended with nausea or pain. It may be a premon- 
itory symptom of apoplexy or associated with meningitis, hydrocephalus, 
brain concussion, etc. 
262 



SECRETORY PHENOMENA OF THE STOMACH 263 

Spasms of the stomach, pylorus, or cardia are frequently observed, also 
peristaltic unrest and peristaltic atony. 

Dilatation of the Stomach. — A dilated stomach acts like a dilated heart 
— its cavity does not empty itself. Pyloric stenosis is accompanied by 
dilatation of the stomach and is often compensated by hypertrophy of 
the gastric muscularis with subsequent degeneration of the muscular 
elements. Anomalies of form and position favor such changes, and then 
we speak of motor insufficiency. 

A dilatation without pyloric stenosis is found in connection with super- 
secretion, hyperacidity, and neurasthenia. Atony of the stomach may be 
due to undue fermentation and may cause undue fermentation or putre- 
faction. 

Speaking generally, we may affirm that in atony without dilatation the 
stomach is empty if examined in the morning before breakfast. This 
denotes weak peristalsis. 

In atonic dilatation the stomach is not obstructed, but is unable to empty 
itself, and food is found in washing the stomach in the morning. 

In dilatation due to pyloric obstruction we speak of secondary dilatation 
as we find it in cancerous, fibrous, or cicatricial obstruction. The wash water 
will show food in all stages of putrefaction. 

Sensory Phenomena of the Stomach 

In health we feel the stomach when we are hungry or when we overload 
it, and a sick stomach will show the overloaded feeling after a small quantity 
of food has been taken. Actual pain in the stomach (gastralgia) is constant 
in ulcers and cancer from irritation of HCl and organic acids. Clonic 
muscular contraction in the walls of the stomach and intestine also pro- 
duces pain. Neuralgia of the stomach is observed in stomach neurasthenics 
and in tabetic subjects. Many phenomena in various parts of the body 
are of gastric origin, such as epileptoid and tetanic seizures, vasomotor 
phenomena, parsesthesias, and neuralgias of various parts, also migraine, 
vertigo, cardiac irregularities, and asthmatic complaints. 

Disorders of the Appetite. — Anorexia is a simple loss of appetite often 
observed in old people, in nervous people, and in persons who are under 
great mental strain (anorexia mentalis). Polyphagia, or bulimia, may 
be permanent or paroxysmal. It is an inordinate craving for food in con- 
valescence from febrile disease and in some insanities and hysteria, etc. 
Akoria is a feeling of emptiness. Pica is a craving for unusual substances, 
observed in hysteria, idiots, and children. Thirst may be increased or 
annulled in fever, in diabetes, or from a dry mouth. Idiosyncrasies are 
aversion to certain foods. 

Other sensory phenomena are anoesthesia, hypercesthesia, parcesthesia, 
nausea, and abnormalities of appetite. 

Secretory Phenomena of the Stomach 

Gastric Juice. — Healthy individuals may have a small quantity of 
gastric juice in an empty stomach. When this quantity is increased, we 



264 THE DIGESTIVE SYSTEM 

speak of supersecretion with or without hyperacidity (1 to 2 per cent). 
Such conditions are known to be present in chronic dyspepsia, in neuras- 
thenia, and in serious nervous disease, such as locomotor ataxia. Therefore 
not every case of dyspepsia has its origin in the stomach or requires local 
treatment. Stomach supersecretion may be a distinct nervous manifesta- 
tion similar to salivation in bulbar paralysis. Superacidity without super- 
secretion is a common occurrence in ulcer of the stomach. Supersecretion 
and superacidity are usually associated with pain, vomiting, dilatation of 
the stomach, and cachexia. 

Injuries of the stomach mucosa or a localized venous thrombosis are 
apt to turn into peptic ulcer when supersecretion is present. Mycotic 
necrosis is another potent factor in the causation of peptic ulcers. 

Stagnation. — Stagnation of the stomach contents favors microbiotic 
action. If stagnation and free HCl go together, putrid fermentation is 
rare. Stagnation and anacidity favor putrid action. When undue fer- 
mentation exists without motor or secretory disturbances, the quality 
and quantity of food are usually at fault and the cause of dyspeptic 
symptoms. 

The secretory neuroses are called gastrosuccorrhoea, hyperchlorhydria, 
hypochlorhydria, and nervous dyspepsia. 

Hydrochloric Acid, HCl 

Hydrochloric acid is secreted by the stomach and combines with the 
various stomach contents, notably the proteids. The carbohydrates are 
acted upon by the saliva. In healthy adult stomachs HCl is secreted in 
such quantities that it can be detected as a free acid. In young infants 
this is not the case. During the height of digestion free HCl reaction 
is present. 

Hyperacidity. — Continuous hyperacidity is found in chlorosis and in 
neurotic dyspepsia, is often present in simple ulcer, and may be a symptom 
of the early stages of chronic gastritis. It speaks against carcinoma except 
when a simple ulcer is undergoing carcinomatous metaplasia. 

Subacidity. — Continuous suhacidity under 1 per cent is found in chronic 
gastritis, especially with dilatation and atony, in some cases of simple ulcer 
with chronic gastritis, and in incipient carcinoma. It is also found in 
anaemia, tuberculosis, and other cachexias. A decrease of HCl interferes 
with the splitting up of the proteids and decreases the antiseptic action of 
the gastric juice. 

Anacidity. — Anacidity is a persistent symptom of the later stages of 
chronic gastritis, when pepsin is also lacking. When pepsin is present, 
it indicates a neurosis. In combination with other signs anacidity speaks 
for carcinoma. 

A true anacidity is rare, but has been observed in cases of achylia gastrica. 

Therapeutic Value of Hydrochloric Acid. — The gastric juice possesses 
antiseptic and germicidal properties. These properties are referable to 
the presence of free HCl. A subnormal amount of HCl will call forth an 
increased amount of intestinal putrefaction (subacidity, anacidity). A 
normal acidity of the gastric juice is never associated with increased 



DIGESTIVE FERMENTS 265 

indicanuria, except in ulcer, when hyperchlorhydria and increased indica- 
nuria go together. 

For supplementing the digestive work of the stomach and improving 
the appetite, the author has used HCl for twenty-five years of his professional 
life in adults and in children oyer two years of age, and there is no drug in 
the pharmacopoeia which has given him more satisfaction. The indication 
has been a coated tongue, irrespective of the underlying condition, and 
even in cases of fermentative dyspepsia with acid eructation, the adminis- 
tration of HCl has been followed by far happier results than resulted from 
the administration of alkalies. No amount of theoretical reasoning will 
dispose of clinical experience. In only a few cases will the HCl not be 
tolerated, and if the tongue fails to become clean after its use, there is usually 
some grave organic change in some organ. In the presence of hyperchlor- 
hydria HCl is not indicated. 

Hydrochloric acid favors proteolytic action of the pancreatic juice 
(Rachford), and the therapeutic administration of hydrochloric acid to 
aid digestion finds an additional indication by reason of this fact. The 
beneficial action of hydrochloric acid is not confined to the stomach, but 
as combined hydrochloric acid it is continued in the intestinal canal, where 
it not only aids the pancreatic digestion of casein, but also acts as an in- 
testinal antiseptic. For the mode of administration, see chapter on 
General Therapeutics. 

Bitter tonics, such as nux vomica, strychnine, quassia, gentian, and 
quinine may be given in combination with HCl. 

Digestive ' Ferments 

The principal digestive ferments are ptyalin, pepsin, and pancreatin. 

Ptyalin. — Ptyalin may be practically discarded, for we know very little 
as yet about the altered chemistry of the saliva. Amylaceous dyspepsia 
will hardly exist in a person who chews slowly. The market is flooded with 
preparations of diastase, pure or in combination with laxatives, tonics, 
and antiseptics, but the author- is unable at the present time to give exact 
indications for their use. The pineapple also contains a ferment which can 
be administered as pineapple juice. 

Pepsin. — Marked diminution of this principle or its absence indicates 
a corresponding disturbance of glandular activity. It may exist with a 
variety of lesions. 

Pepsin acts in an acid medium (hydrochloric acid) ; pancreatin acts in 
an alkaline medium. 

Pancreatin. — Pancreatin is practically indicated only in atrophic gas- 
tritis. 

I^ Pancreatin., 



Sodii bicarb., y ^^' Sr.vuj. 

M. Sig.: After meals. 

Other Aids. — Artificial means of aiding digestion (other than HCl) 
are too readily prescribed and ordered at random. In ordinary nervous 
dyspepsia it is best to stimulate the stomach secretions by putting solid 



266 THE DIGESTIVE SYSTEM 

food into the stomach and aiding digestion with a few drops of dilute hydro- 
chloric acid, to be taken in water after meals, not by administering digestive 
ferments. In a case of bilateral parotitis with a dry mouth and no flow of 
saliva the writer has given malt and taka diastase to advantage. 

Lactic acid is not a normal product of stomach digestion. It is often 
ingested with food and forms early in digestion when milk and bread have 
been taken. It is present in larger proportions in dilatation with stagnation 
of contents. If associated with retention and absence of HCl, it makes 
the suspicion of carcinoma strong, but its presence is not pathognomonic 
of carcinoma, because it is also found in functional stomach disorders and 
in gastritis gravis. 

Zymogen. — The production of zymogen is a staple function of the 
stomach mucosa. 

Alkalies neutralize gastric acidity and are supposed to stimulate gastric 
secretion. It is the author's experience that in fermentative dyspepsia 
with acid eructations (fatty acids) without pain, a brisk laxative, followed 
by HCl, is superior to the alkaline management. In hyperacidity and 
ulcer and various forms of dyspepsia with pain after eating the alkalies are 
indicated. Alkalies are indispensable in lavage to dissolve mucus in the 
stomach. The beneficial effects of alkaline mineral waters (Carlsbad, 
Ems, Vichy, Saratoga) are most marked in those cases in which diet, ex- 
ercise, massage, hydrotherapeutics, and freedom from worry are secured. 
Bismuth subcarbonate, magnesium carbonate, and sodium bicarbonate 
are the alkalies usually administered. Alkalies may be combined with 
morphine for the purpose of overcoming severe pain. 

Diagnostic Technique. (See also Laboratory Aids.) 

We determine the location, size, and capacity of the stomach by per- 
cussion, palpation, and auscultatory percussion. The fundus is the highest 
point in the stomach and reaches the level of the ninth dorsal vertebra. 
The lesser curvature is usually covered by the liver; the upper greater 
curvature is covered by the lung; the pylorus is covered by the right lobe 
of the liver. 

Gastric distention can be made out by inflating the stomach. The 
patient swallows a teaspoonful of sodium bicarbonate in eight ounces of 
water, and immediately half a teaspoonful of tartaric acid in the same amount 
of water. An evolution of CO2 takes place in the stomach, and the organ 
stands out prominently and can readily be palpated or percussed. Loca- 
tion, size, and capacity determinations are more or less fallacious, but can 
be made by auscultatory percussion (Platschergerausch splashing sound). 
Gastrodiaphany, or transillumination of the human stomach by means 
of a swallowed small electric lamp, was first practised by Dr. Einhorn, of 
New York. 

Transillumination of the stomach with fluorescein was introduced by 
Kemp and Lincoln, of New York. It may be used in stout as well as thin 
persons with good results; even in the colored race the results are fair. 
The method employed is as follows: Give the patient 10 gr. or more of 
quinine during the day of examination or the day previous. Introduce 



DIAGNOSTIC TECHNIQUE 



267 



the lamp. Have the patient drink a glass of water in which has been 
dissolved 30 to 40 gr. of sodium bicarbonate, to render the gastric contents 
alkaline. Allow another glass of water to be taken, into which has been 
placed J gr. of fluorescein, 1 dr. of glycerin, and 20 gr. or more of sodium 
bicarbonate. The abdomen being bared, conduct the patient into the dark 
room, or, if at night, simply turn out the lights. It is better to introduce 
the lamp before the solution, so that should there by any chance be any 
trouble, the fluorescein will not be vomited. 

X Ray Examination. — By introducing a soft rubber tube with a me- 
tallic chain in its centre, the location of the stomach can be ascertained 
as a shadowgraph. Bismuth powder thrown into the stomach with a 




L_jjtiJ3:r5**ji 



Fig. 108. — Ilu'mixaiiox of iiii-. Siomach hv mi;.\n> 
AND THE Electric Light. 



■ l.tOHHSt-EIINr 



powder blower might facilitate the taking of an x ray stomach shadow. 
Illumination of the stomach by means of radium is unsatisfactory. 

Method of Testing the Motor Function of the Stomach. — The peristaltic 
function of the stomach is the most important one, because the secretory 
and resorptive function of the stomach may be assumed by the intestines. 
When the motor function of the stomach is interfered with, food must 
remain in the stomach and accumulate and finally be vomited as in pyloric 
stenosis. There are six or seven methods of testing the motor functions 
of the stomach. The simplest for the general practitioner are the tests 
of Leube and Ewald. 

Leube's Test. — Give a test breakfast and ascertain by means of the stom- 
ach tube after two hours whether solid contents are still to be found in the 



268 THE DIGESTIVE SYSTEM 

stomach. When the tube is in the stomach the patient strains as if at stool. 
If no contents arise, push the tube in or out and use external pressure over 
the stomach. If nothing arises, the stomach is empty or the tube is blocked 
by large portions of food. To ascertain the latter, pour in half a pint of 
water through a funnel. If nothing but water returns, the test meal has 
passed into the intestines. 

Ewald's Test. — Give one grain of salol. Normally it can be recognized 
in the urine in from forty to seventy-five minutes. Delay in its appearance 
will indicate a retardation of the passage of food into the intestine. It is 
recognized in the urine by the violet color produced on the addition of 
neutral ferric chloride. 

The "scHLUCKGERAuscH," heard at the ensiform cartilage, is of diag- 
nostic import in stricture of the oesophagus and cardia, but in the absence 
of such lesions it is a variable phenomenon. 

The chemical examination of the stomach contents is made by siphoning 
out the stomach after a test meal and applying the tests as given in the 
chapter on Laboratory Diagnosis. 

EwALD AND Boas Test Breakfast. — One piece of wheat bread, one 
pint of water or tea without milk or sugar. Time for examination, one 
hour after the meal. 

Leube and Riegel Test Dinner. — A plate of soup and a portion of 
roast beef. Time for examination, three to four hours after meal. 

Fleiner's Test Meal. — Soup, roast beef, and potato pur6e. Time 
for examination, three to four hours after meal. 

Double Test Meal. — 8 a.m. Two and a half ounces of scraped and 
broiled beef, one soft boiled egg, one ounce of boiled rice, one glass of milk, 
a piece of bread. 

12 m. Follow at noon by Ewald's breakfast. Examine one hour later. 

Gross Interpretation. — The absence of all proteids and the presence of 
carbohydrates, rice, and bread point to hyperchlorhydria. The presence 
of the entire meal, with milk uncurdled, means impaired motility, atrophy 
of the mucosa, or absence of acid. (See also Laboratory Diagnosis.) 

To Test Gastric Resorption. — Method of Penzold and Faher: Five 
grains of potassium iodide are swallowed in a wafer with three and a half 
ounces of water. It can be detected in the saliva and urine in from six 
and a half to eighteen minutes by means of starch paper, which, when wet 
with saliva or urine and touched with fuming nitric acid, shows the blue 
iodine reaction. There is a reduced absorption in carcinoma. 

For Sahli's test for gastric absorption see Laboratory Aids. 

REMARKS ON THE CLINICAL PATHOLOGY OF THE INTESTINE 

Experiments have shown that in the absence of bile in the intestine 
proteids and carbohydrates undergo their usual metabolic changes^ and 
about 60 per cent of fats are not absorbed. They are split up by bacteria 
and by the pancreatic juice, and their products irritate the intestine. Thus 
fats are harmful in the absence of bile. Bile has a certain antiseptic power 
over intestinal bacteria, and as the absence of bile favors constipation, an 
overproduction of bacteria results. The absence of pancreatic juice in 



MOTOR PHENOMENA OF THE INTESTINE 269 

the intestine is rare. There are two openings of the pancreatic duct. The 
duct is seldom closed by concrements, and a complete degeneration of the 
organ is rare. We have no very reliable data regarding the behavior of pro- 
teids and carbohydrates in the absence of pancreatic juice, but it is certain 
that much of the fat taken into the body is found unchanged in the faeces. 

The intestine receives from without with the food and drink a great 
variety of substances, including pathogenic and non-pathogenic bacteria, 
and behaves toward them according to condition and idiosyncrasy. Food 
ptomaines are absorbed by the intestine and injure it or poison the organism. 
Many bacteria which get into the stomach are killed therein, others lose 
their virulency, and still others go unchanged into the intestine. Those 
able to withstand an acid medium become active in the small intestine; 
others thrive in neutral or alkaline media and develop in the colon, where 
there is less peristalsis. 

An invasion of the organism by bacteria is hindered by an intact epithelial 
lining, but soluble products of bacterial action are absorbed and may offer 
to the organism a protection against the bacteria themselves. Patho- 
genic bacteria may die in an acid stomach or pass through the intestine 
and fail to find a foothold in the intestinal mucosa. The cholera vibrio 
is particularly virulent in dyspeptics with subacidity. 

The substances which originate in the intestine and irritate the same 
are lactic, butyric, and acetic acids, sulphureted hydrogen, aromatic bodies, 
bacterial poisons, and ptomaines. The frequent complication of nephritis 
in the course of intestinal troubles is due to the absorption of poisons. In 
endemic dysentery protozoa (amoeba) have been found in the intestine. 

Absorption of nutritive material takes place principally in the small 
intestine. Sugar and albumen are taken into the blood, and fat is taken 
into the lymphatics. In diseased conditions the power of absorption is 
lessened, and diarrhoea results. In some forms of diarrhoea the liquid stools 
are due to increased transudation of the intestine 

Motor Phenomena 

Singultus, or hiccough, results from sudden contraction of the diaphragm. 
The mild form of hiccough is of little importance, but its occurrence in 
serious illness adds to the gravity of the prognosis. (See also chapter on 
General Therapeutics.) 

Nervous constipation and nervous diarrhoea are discussed under Con- 
stipation and Diarrhoea. 

Enteros'pasm and proctospasm are contractures of the muscular fibres 
of the intestine and rectum, with and without pain, causing transient 
constipation or obstruction of the bowel. 

Peristaltic unrest and retroperistalsis are motor phenomena of the in- 
testine observed in bowel obstruction and also in neurotics. 

Atony of the intestine is frequently observed in atrophic and rhachitic 
infants, in neurasthenic adults, and in paresis and paralysis of the intestinal 
muscularis from local or central cause. The abdomen is usually tympanitic, 
and auscultation shows absence of gurgling gut sounds, moreover, the 
intestine does not empty itself. 



270 THE DIGESTIVE SYSTEM 

Sensory Phenomena 

Colic and painful crises are frequently observed. When gall stones and 
renal colic can be ruled out, there may be intestinal colic from various 
causes — flatulence, appendicular colic, lead colic, mucous colic, and crises of 
nervous disease. 

Rectal neuralgia without appreciable local cause is observed in anaemic 
and neurotic individuals. (See Rectum.) 

Secretory phenomena, such as nervous diarrhoea and colica mucosa, are 
discussed clinically. 

Diagnostic Technique. (See also Laboratory Aids.) 

Inspection. — Simple inspection of the abdomen may show enlargement, 
retraction, and venous distention, if either of these conditions is present. 
Exaggerated contraction is noticeable through the abdominal walls. When 
there is undue relaxation the belly flattens out when the patient is on his 
back, and falls downward like a half filled sack when the patient stands 
(enteroptosis) . 

Palpation should be done in a warm room, and in some instances a 
relaxation of the abdomen is best secured by placing and examining the 
patient in a warm bath or anaesthetizing him. Palpation elicits a gurgling 
sound and a splashing sound over the stomach or colon. Tumors are 
intraperitoneal and extraperitoneal, and phantom tumors can be indented 
by pressure. Where there is inflammation, pain or tenderness is elicited 
on pressure and also a feeling of resistance when the parts are lax. 

Palpation of the appendix and incidentally the kidneys is readily possible. 
These organs can be felt in children and adults in most cases in which a care- 
ful search is made. 

Percussion is less important than palpation. A distended gut gives a 
tympanitic sound ; a collapsed gut or one filled with liquids or solids shows 
dulness. An abdominal effusion changes its position with the changed 
position of the patient, unless it is encysted or confined by adhesions. 

Auscultation reveals undue or absent peristalsis and the gurgling and 
splashing sound, but furnishes no valuable data otherwise. The rectum 
may be explored by the finger protected by a finger cot, or by means of a 
speculum and light. 

Transillumination after a cleansing enema has little practical value. 

An X ray examination of the lower gut can be made with the aid of a 
wire encased in a soft rectal tube, which can be inserted up to the sigmoid 
flexure, or by means of a high injection of starch water in which subnitrate 
of bismuth is suspended. Such a fluid will gravitate to the colon in the 
dorsal posture with the hips elevated. 

Inflation of the lower gut by means of an inverted siphon or by injecting 
air with a bicycle pump is easily accomplished. An inflated colon will lie 
in front of a kidney tumor or retroperitoneal glands and behind or below 
an enlarged spleen. The colon can be inflated by gas, water, or oil in the 
genupectoral position. (See also Laboratory Diagnosis.) 

Examination of the FaBces. — The quantity, consistence, and character 
of the faeces vary. In the small intestine the stool is liquid ; its consistence 



i 



DIAGNOSTIC TECHNIQUE 271 

and form are attained in the colon. If there is rapid peristalsis or increased 
secretion in the colon, the stools are also liquid. Decreased secretion will 
favor dry stools. In chronic constipation the stool forms into small 
scybala. Spastic constipation or stricture may furnish a small calibre 
stool. The color is influenced by what has been taken into the stomach 
(iron, bismuth, blackberries, etc). 

Gmelin's bile reaction is not found in the faeces normally. When found 
it indicates a disturbance in the small intestine and rapid peristalsis. Gray 
stools indicate an absence of bile in the intestinal tract, but it should be 
borne in mind that gray stools are also observed in tuberculosis of the intes- 
tines, in leucaemia, and in carcinosis. Vegetables and milk give an abundant 
stool. The reaction of the faeces is alkaline except in fermentative diarrhoea. 
Lientery is that condition in which remnants of food or fat or starch are 
found in the stools. Starch in the stool in considerable quantities is always 
pathological. We may find in the stool remnants of food, found in every 
stool (starch rarely) ; fragments of tumors and tissues (carcinoma, dysen- 
tery) ; concretions — enteroliths, coproliths, gallstones, foreign bodies; pus in 
abscess, dysentery, or syphilitic, tuberculous, or carcinomatous ulceration; 
blood, in injury, endarteritis, infection, intoxication, congestion from dis- 
turbed circulation, haemorrhoids, and ulceration. When small quantities 
of blood are found in the stools of typhoid fever patients, we should be 
on the lookout for profuse haemorrhages. Blood from the stomach or duo- 
denum is usually black or tarlike. 

Mucus may be of vegetable origin and resemble frog spawn. It is 
usually the product of irritation and catarrh of Lieberkiihn's glands. No 
mucus, no catarrh. Colica mucosa is observed in neurotics. Yellow 
mucus (bile) means catarrh of the small intestine (duodenal catarrh). 
Mucus in the stools may indicate constipation, piles, enteroptosis, worms, 
intestinal adhesions, or nervous colic. 

Fibrin. — Membranes in the stools are generally mucus. Erhlich's 
triacid solution colors mucus green, fibrin red. (See Laboratory Aids.) 

Fat is always found in drops or crystals. Large quantities are found in 
defective absorption, in fat diarrhoea of children, and in hepatic and pan- 
creatic disease. 

Bile. — Normally there is no bile reaction in the stools. When it is 
present it indicates catarrh of the small intestine. The stools of children 
colored green by bile resemble "green bacillus " stools. 

Parasites. — Worms, protozoa, amoeba. 

Crystals. — The so called Charcot crystals speak for worms in the in- 
testine. 

Bacteria. — In the present state of our knowledge no exact clinical de- 
ductions can be drawn from the enormous number of bacteria found in 
the stools, except when cholera, typhoid, tuberculosis, or bubonic microbes, 
etc., are found. 

For careful investigation of the stools the employment of a stool sieve 
is necessary. (See Laboratory Diagnosis.) 

For lavage, flushing the colon, and enteroclysis, see chapter on General 
Therapeutics. 



272 THE DIGESTIVE SYSTEM 



CONCLUSIONS 

It is admitted by the majority of clinicians that a chemical examination 
of the stomach contents is of minor practical importance as compared with 
a good insight into the motor function. To rely upon secretory phenomena 
in forming a diagnosis, prognosis, and treatment is a grave mistake. The 
early recognition of organic stomach disease is of great importance, and in 
long standing dyspepsia with considerable loss of weight and in the absence 
of a palpable tumor or stricture an examination under narcosis or an ex- 
ploratory laparotomy is justified. 

The introduction of a stomach tube is usually contraindicated in the 
advanced stages of heart disease, in aneurysm, pulmonary hsemorrhage, 
advanced cachexia, pulmonary tuberculosis, apoplexy, cerebral hyperaemia, 
and ulcer of the stomach with recent haematemesis and dark stools, or when 
the stomach mucosa easily bleeds. 

In summing up, we may state that the gastroenteric tract has a triple 
function: Mechanical, chemical, and absorptive. Any disturbance of 
these functions is followed by a simple or inflammatory dyspepsia and 
malnutrition. Fermentative and putrid changes in the mouth may travel 
into the stomach and intestines. It is of importance to know whether a 
disturbance of digestion is due to infection or motor disturbance or is of 
neurotic origin, and it is important to remember that the susceptibility 
to infection and catarrhal conditions of the gastroenteric tract is different 
in different individuals, and thus we have clinically weak and strong stomachs. 



CHAPTER Vin 

THE DIGESTIVE SYSTEM~C ontinued 

GASTROINTESTINAL AILMENTS IN ADULTS 

Synopsis: Acute Dyspepsia and Gastritis, Diet, Medication. — Chronic Dyspepsia with and 
without Dilatation and Atony, Varieties, Specimen Diet, Treatment. — Dyspepsia of 
Pregnancy. — Secretory Neuroses of the Stomach. — Erosion and Ulcer of the Stomach, 
CUnical Varieties of Ulcer. — Cancer of the Stomach. — Benign Tumors. — Haemorrhage 
from the Stomach. — Gastrointestinal Neuralgia, Cardialgia, Gastralgia, Enteralgia, 
Colic, Stomach Cramps, Differentiation, Treatment. — Indications for Operation of the 
Stomach. — Constipation and Fsecal Impaction. — Faecal Tumors. — Diarrhoeas and In- 
continence, Clinical Forms. — Tympanites and Dilatation of the Colon. — Inflammatory 
Disorders of the Intestines, Acute and Chronic. — Enteritis. — Gastroenteritis and 
Dysentery. — Dysentery. — Ulcer of the Intestines. — Appendicitis, General Indications 
for Operation. — Neoplasms of the Intestines.— Bowel Obstruction. — Haemorrhage 
from the Intestines. — Remarks on Strangulated Hernia and Taxis. — Intestinal 
Parasites. — Hook Worm Disease. — Enteroptosis. — Intestinal Indigestion, Treatment 
by Diet, Exercise, Baths, Medication. 

ACUTE DYSPEPSIA ; ACUTE INDIGESTION ; GASTRICISMUS 

■ etiology. — The disease is due to dietetic imprudence, overeating, un- 
suitable or decomposing food or abuse of alcoholic beverages. 

Symptoms. — Headache, a dull feeling, epigastric fulness, dull pain in 
epigastrium, nausea, eructations, vomiting, coated tongue, foetor ex ore, 
a bad taste in the mouth. The attack may last from two to five days. 
Constipation or diarrhoea may be associated with acute dyspepsia. 

Treatment. — Diet. — Carbonated water, slimy soup, meat broth or beef 
tea, peppermint tea or black tea, or total abstinence from food for from 
twelve to twenty-four hours. 

Medication. — Five to ten grains of calomel followed by a saline cathar- 
tic, and on the following day five drops of dilute hydrochloric acid in sugar 
water, four times a day, and a long walk in the fresh air. 

Prognosis favorable. (For acute indigestion in children, see Paediatrics.) 

Acute Gastritis, Simple, Phlegmonous, Toxic, «Infectious, Parasitic 

This is the severe form of acute dyspepsia. There are, in addition to 
the ordinary symptoms mentioned above, pain, tympanites, high colored, 
scanty urine, and occasionally slight jaundice. The management is the 
same as in ordinary acute indigestion, but a strict diet will have to be kept 

273 



274 THE DIGESTIVE SYSTEM 

up for a longer period, and in addition the following prescription is very 
serviceable to control pain and vomiting in adults: 

I^ Morph. sulph., gr- j ; 

Aquae amygd. amar., ) __ ^. 

Tinct. valerian, aether., \ ' •'' 

Aquae carbonicse, ad, 5 v. 

M. S.: One half to one tablespoonful every two hours. Keep on 
ice. Do not shake the bottle. 

In some cases morphine should be given hypodermically. 

In addition to simple acute gastritis, there are the phlegmonous gas- 
tritis secondary to cancer or septic peritonitis and other processes, toxic 
gastritis from the ingestion of corrosive poisons (see Poisons), infectious 
gastritis, which is observed during severe infectious disease (scarlatina, 
etc.), and a parasitic gastritis, or mould in the stomach. 

Prognosis. — The prognosis of all forms of severe gastritis will depend 
upon the underlying cause. In the very young and the aged or in cachectic 
individuals the prognosis is very grave. 

Treatment. — The treatment is symptomatic, as in acute simple gastritis. 

CHRONIC DYSPEPSIA 

Dyspepsia, although only a symptom indicating a disturbance of some 
kind, rises in practice, like convulsions, to the dignity of an ailment. The 
laity invariably associate the symptom "dyspepsia " with the stomach 
proper, and thus the stomach specialist may bask in the sunshine of all the 
ills that flesh is heir to, because all sickness is accompanied more or less 
by dyspepsia or a loss of appetite. 

It is the duty of the physician to make a careful clinical examination 
of his patient in long standing dyspepsia, and after excluding heart, lung, 
kidney, liver, brain, and nerve disease, he will finally come by exclusion 
to the consideration of a primary dyspepsia having its origin in some dis- 
order of the gastroenteric tract, and our modern methods of examination 
will enable him to tell whether he has to deal with an inflammatory or 
secretory disturbance or a motor insufficiency (muscular or stenotic) or 
ulcer or new growth. 

When dyspepsia is secondary to, or concomitant with, other organic 
disease, our efforts to overcome dyspepsia will be futile unless we recognize 
and direct our therapeutic efforts to the primary ailment. We must 
always bear in mind that chronic indigestion must be viewed in its relation 
to the whole gastroenteric tract, and not in relation to the stomach alone. 

Clinical Varieties of Chronic Dyspepsia 

Chronic Gastric Catarrh. — The primary causes of this ailment are dietetic 
errors and the excessive use of alcoholic beverages. It may be secondary 
to any chronic constitutional or organic disease of the heart, lungs, liver, 
kidneys, etc. 

Symptoms. — There may be general malaise, coated tongue, bad taste in 
the mouth, metallic taste, headache, vertigo, fickle appetite, epigastric 



CHRONIC DYSPEPSIA 275 

oppression after eating, or "heartburn," local tenderness, eructations of 
bitter fluid, belching of gas, tympanites, vomiting after meals, morning 
vomiting or dry retching of watery mucus in alcoholism. Constipation 
and diarrhoea may alternate. Palpitation of the heart is common, and 
a "stomach cough " is generally due to chronic pharyngitis. The urine 
is usually high colored and shows a heavy deposit. 

An examination of the stomach contents enables us to recognize three 
forms of chronic gastritis: 

1. Simple Chronic Gastritis. — HCl diminished. Fasting stomach con- 
tains a little slimy fluid. 

2. Miicoiis Gastritis. — HCl diminished. Large amount of mucus present. 

3. Atrophic Gastritis. — HCl and pepsin absent. Fasting stomach empty. 
The symptoms of atrophic gastritis resemble those of cancer (tumor 
absent) or pernicious anemia and are accompanied by pain, vomiting, and 
progressive emaciation. 

The PROGNOSIS of chronic gastric catarrh is good, but it will take time 
to effect a cure. If atrophy has taken place, the prognosis is unfavorable. 

Treatment. — When the diagnosis of chronic gastric catarrh is made, 
the patient may take one dose of podophyllin as follows: 

I^ Podophylli, gr. ^ ; 

Calomel, gr. x; 

Pulv. aromat., gr. iij. 

M. Sig. : Take at bedtime. 

Every morning before breakfast the patient should sip a cup of hot 
water in which is dissolved a teaspoonful of Carlsbad salt in case of chronic 
constipation. Should the Carlsbad salt not agree with the patient, an 
enema or a " lapactic " pill may be taken before going to bed. As a rule 
cases of chronic gastric catarrh do not irnprove unless the bowels move 
freely once a day. 

SPECIMEN DIET 

On rising, one cup of hot water. 

8 A. M., one bowl of slimy soup with or without egg, or two scrambled 
eggs with toast, or two raw eggs with salt, tea, toast, zwieback. Avoid fats. 

11 A. M., one cup of bouillon with egg or eat a piece of sweet chocolate. 

12 to 1, plain soup or bouillon, raw scraped meat or lamb chop or 
scrambled eggs, fresh green salad, rice, stewed fruit, and tea. 

6 p. M., cold meat, beef, chicken, turkey, raw ham, raw oysters, caviar 
sandwich with lemon juice, raw meat sandwich, meat jelly, salt sardelles, 
buttermilk, tea, cocoa, toast, etc. 

Milk or buttermilk may be taken with any meal if it agrees. Hydro- 
chloric acid will aid digestion if taken after each large meal. HCl may be 
given in water or in combination with essence of pepsin or with bitter tonics 
(see General Therapeutics). Occasionally HCl will not agree, and then it 
will be well to give the following alkaline powder after eating: 

R Bismuth, subcarb., 1 __ , 

'^ ,, ^ > aa, gr. V to X. 

Magnes. ust., J 

19 



276 THE DIGESTIVE SYSTEM 

Beer should be forbidden. A glass of Rhine or Moselle wine or a tea- 
spoonful of whiskey in water after meals may be allowed as an experiment. 
At the same time the patient should have exercise (walking, bicycling, 
punching bag, horseback riding), and should be free from worry; if 
necessary, he should go away from home to secure it. General mild 
massage and vibratory message of the stomach are very important adjuvants 
to the treatment, also loarm baths or cool douches. As the patient improves, 
the diet may be more liberal, avoiding dense cheese, fried potatoes, fatty 
sauces, cabbage, beans, mayonnaise, beer, pastry, and raw fruit. Contrary 
to universal prejudice, the writer has only occasionally found it necessary 
to eliminate from the diet salt pickles, green salads, and soft mature cheese. 

When such management fails to improve the patient, stomach 'washing 
is indicated, particularly in cases with much mucus in the stomach. Two 
to three quarts of warm water containing half an ounce of bicarbonate of 
sodium are used. The best time to wash the stomach is one half to one 
hour before breakfast. Stomach washing may be continued for from 
two to six months. (See General Therapeutics.) 

DYSPEPSIA WITH DILATATION OR ATONY OF THE STOMACH 

There are three varieties of stomach dilatation: 1. Acute dilatation. 2. 
Dilatation due to stricture or narrowing of the pylorus or duodenum, malig- 
nant or non-malignant. 3. Dilatation due to chronic gastric catarrh or 
habitual overdistention (beer drinkers, overfeeding of infants) and degenera- 
tive changes from wasting disease. 

Symptoms.— Anacidity, hyperacidity, and normal acidity may be asso- 
ciated with dilatation. In addition to ordinary dyspeptic symptoms, 
we notice a characteristic vomiting of large quantities of stagnant fluid. 
The vomit is acid, from the presence of lactic, butyric, and acetic acids, 
and offensive to the smell. The fluid contains particles of food, the Sarcina 
verdriculi, yeast fungus, and bacteria. Auscultatory percussion and in- 
flation by air or transillumination will determine the outlines of the stomach, 
and a splashing and succussion sound may be elicited by the hand. 

Finding a tumor will decide against the atonic nature of the dilatation, 
and in the majority of cases the tumor is cancer. The distinction of benign 
from malignant tumor can be made only by operative inspection. 

The prognosis depends upon the cause. 

Treatment. — In atony due to stricture at the outlet of the stomach 
operative interference is the only help. If the stricture cannot be removed, 
the stomach may be joined to the intestine (gastroenterostomy). In the 
atonic variety lavage, enemata, a dry diet, and vibratory massage are 
the important elements of treatment. As myasthenia is not uncommon 
in students and persons leading a sedentary life, an active out of door life 
should be encouraged. In enteroptosis an abdominal binder should be worn. 

SPECIMEN DIET FOB DILATATION 

Scraped meat, scraped ham, smoked beef, game, fowl, soft eggs, cereals 
(all kinds) and cream, beef, or meat jelly, extract of malt, boiled beef, 
oysters, raw or stewed, puree of potatoes, lentils, peas, omelette souffle, 



CHROxNIC NERVOUS DYSPEPSIA , 277 

zwieback, crackers, toast, caviar, cocoa, chocolate, tea, tropon, Tokay or 
Malaga wine, whiskey in teaspoonful doses in water. 

Other articles may be selected from the general diet lists. The 
amount of liquids taken should not exceed three pints in twenty-four 
hours. In some instances rectal feeding becomes necessary for a time, 
particularly in severe vomiting and pain. 

Medication. — Hydrochloric acid or tincture of nux vomica is to be 
given after eating. Morphine subcutaneously may be necessary in extreme 
cases with excruciating pain. Strychnine in dilute phosphoric acid, gr. 1 
ad 5j, ten drops three times a day, is useful. Massage and vibratory 
massage and hydrotherapy (cold douche or spray to the region of the 
stomach) are of great importance. Some patients do well by wearing a 
moist towel around the abdomen day and night (Neptune's girdle), and 
in other cases an abdominal bandage gives comfort and relief. 

Operative Treatment. — In otherwise incurable simple atonic dilata- 
tion excision of a part of the stomach wall (gastroplication, or gastror- 
rhaphy) has been done. Before operating upon the stomach proper, we 
should be absolutely certain that the obstruction to the flow of chyme is 
not somewhere outside of the stomach. 



CHRONIC NERVOUS DYSPEPSIA 

Nervous dyspepsia is a generic name covering sensory, motor, and 
secretory neuroses. Neurasthenic individuals generally have some special 
organ which gives them particular trouble. The stomach neurasthenic 
has many or all of the symptoms enumerated under dyspepsia, and is a 
hypochondriac in addition. But in spite of these symptoms the stomach 
is found to be empty six or seven hours after a full meal, showing that there is 
no stagnation in the stomach. The gastric juice is usually normal, but it 
may be increased or diminished. In nervous dyspepsia there is very little 
epigastric tenderness, and usually a powerful throbbing of the abdominal 
aorta, particularly in women, is noticed. 

Diagnosis. — The diagnosis rests upon a recognition of the existence of 
a neuropathic constitution and the absence of organic disease. The distinction 
of nervous dyspepsia from ulcer becomes difficult only in those cases in 
which there has been no vomiting of blood. In ulcer gastric pain is regularly 
dependent upon eating, and there are circumscribed pain points in the 
epigastric region and in the back. In chronic gastric catarrh there is much 
vomiting of mucus, occasionally blood streaked. In cancer the distress 
is present, with and without food in the stomach, and HCl secretion is 
usually absent. 

Prognosis. — The prognosis in nervous dyspepsia is favorable. 

Treatment. — Correct bad habits, hunt up and remove the underlying 
cause, such as floating kidney or enteroptosis (abdominal binder). Enjoin 
rest from mental and bodily overwork, urge change of environment and 
employ gymnastics, general massage, and static electricity. Stomach 
washing is not indicated in nervous dyspepsia. 



278 THE DIGESTIVE SYSTEM 

Diet. — There is no orthodox diet for nervous dyspepsia. A liberal 
mixed diet is to be advised, avoiding cabbage, pastry, rich dressings, beans, 
pears, fried oysters, and clams. A purely liquid diet and peptonized food 
are to be condemned for this class of cases. As regards diet, the statement 
must be most emphatically reiterated that no ironclad rules can be given. 
A fluid diet is to be avoided if possible, and the patient's tastes and idiosyn- 
crasies are to be taken into consideration. It is a better plan to start 
with a liberal miscellaneous diet, and gradually eliminate articles which 
disagree, than to start with fluid or peptonized food and gradually build 
up. The bowels should move daily. If the tongue is coated, half a tea- 
spoonful of Horsford's acid phosphates may be taken in water after meals 
or five drops of dilute hydrochloric acid. In insomnia chloral and bromide 
of potassium will be necessary occasionally at bedtime. Some neurasthenics 
sleep well if they take beer or porter with a salt cracker before going to bed. 
Nervous dyspeptics must understand that the " heart thumping " is not 
heart disease. In fact, "mind cure " applied with tact will work wonders. 
In some instances a Weir Mitchell rest cure is advisable. 

The Dyspepsia of Pregnancy is partly neurotic and partly due to cir- 
culatory disturbances. Vomiting is best controlled by chloral hydrate 
and bromides. HCl after eating and general hygienic management are 
indicated. 

SECRETORY NEUROSIS OF THE STOMACH 

The terms supersecretion, hyperacidity, anacidity, gastrosiiccorrhcea, 
and achylia gastrica are employed to denote certain anomalies of secretion 
as observed in the modern analysis of stomach contents. Such disturbances 
are functional without discoverable local lesion. They may be of reflex 
origin, they may be temporary or more or less permanent, they may exist 
with and without indigestion, and they cannot be identified with any uniform 
or characteristic symptom group. Such manifestations will receive brief 
mention with the distinct understanding that they rrmst not be looked upon 
as a separate, tangible disease but simply accepted as ^^ conditions." 

Dyspepsia with Hyperchlorhydria (Hyperacidity) 

One hour after Ewald's breakfast the stomach contains an excess of 
HCl (free HCl). Three to four hours after a meal the meats are found 
digested, the starchy food is almost unchanged. This condition may show 
periodically or be continuous. 

S3anptoms. — Cardinal Symptoms. — Burning pain two to three hours 
after eating, and hyperacidity. 

Points in Differential Diagnosis. — In gallstone colic the pain is 
more in the right hypochondrium and is not relieved by alkalies or food. 
In gastric ulcer, which is also accompanied by hyperchlorhydria, there is 
bloody vomit with no complete relief from alkalies. There is increased 
pain from food. In supersecretion we find a large amount of gastric juice 
in the fasting stomach. 

Treatment. — Wearing of an abdominal support. General hygienic man- 
agement of dyspepsia with hyperacidity. 



EROSIONS AND ULCER OF THE STOMACH 279 

Diet. — A generous diet with proteids in excess is indicated theoretically. 
However, some cases do remarkably well on a diet in which there is a pre- 
ponderance of cereals and fat (cream). Start with a liberal miscellaneous 
diet and gradually eliminate whatever is found to disagree. Beer, fresh 
bread, pastry, cabbage, raw fruit, and fresh oysters usually disagree. 

The MEDICATION is alkaline. Bismuth, with or without morphine, 
bicarbonate of sodium, magnesia, and alkaline waters. The bowels must 
move freely. Lavage may be necessary. 

Other Forms. — Dyspepsia and continuous or periodic supersecretion of 
gastric juice in the fasting stomach have been recognized. The attacks 
come on with vomiting of acid or greenish gastric juice and pain, headache, 
pallor, and constipation. Before we stamp it as a pure neurosis and treat 
it as such (see Hyperacidity), we must exclude the gastric crises of loco- 
motor ataxia and gastric idcer. 

Dyspepsia and Hypochlorhydria and Achylia Gastrica. — Absence of HCl 
is noticed in cancer of the stomach and in atrophic gastritis. When the 
ferments are also absent, the term achylia gastrica has been used by Ein- 
horn, of New York. An examination of the stomach contents will reveal 
the actual condition present. The administration of HCl is indicated 
after each meal. 



EROSIONS AND ULCER OF THE STOMACH 

Peptic ulcer, duodenal idcer is most common in women between twenty 
and thirty years of age and is often associated with chlorosis, overwork, 
and hepatic and cardiac disease. Arteriosclerosis predisposes to gastric 
ulcer. Duodenal ulcer has been observed in infants. 

Symptoms. — Dyspeptic symptoms Avith localized pain and vomiting 
of blood, grave anaemia, loss of weight, and hyperacidity are the character- 
istics of gastric ulcer. The pain is burning and acute and made worse by 
pressure and food. Hsematemesis occurs in 50 per cent of the cases. In 
duodenal ulcer there are localized pain, occasionally blood in the stools, 
ansemia, and loss of weight. 

Termination and Prognosis. — Gastric and duodenal ulcer may terminate 
by healing, it may perforate and cause peritonitis, it may lead to death by 
inanition or haemorrhage, or it may heal with cicatricial contracture and 
cause obstruction. The prognosis is therefore to be guarded. 

Clinical Varieties of Ulcer. — 1. Light attacks with pain, hyperacidity, 
pyrosis, no hsematemesis; 2. Severe attacks with hamatemesis; 3. Old 
chronic latent and relapsing cases with occasional haemorrhage. 

Differential Diagnosis. — Cardinal Symptoms of Ulcer of the Stomach. — 
Dyspepsia, cardialgia, hsematemesis. If hsematemesis is absent, the diag- 
nosis may be very difficult. In simple gastralgia vomiting of blood is absent 
and the taking of food gives relief from pain. Dyspepsia is usually not 
marked between the attacks of pain. Emaciation is moderate and cir- 
cumscribed tenderness is absent. In the gastric crises of tabes there is 
absence of the knee jerk, with lightning pains in the legs, and the Argyll 
Robertson pupil. Hepatic colic shows swelling and tenderness of the liver 
and frequently jaundice. Hepatic cirrhosis with hsematemesis may simu- 



280 THE DIGESTIVE SYSTEM 

late ulcer, but will show a hard, enlarged liver and ascites. Chronic 
gastritis shows moderate pain, rarely hsematemesis, and rarely hyperacidity. 
Cancer of the stomach shows tumor, absence of HCl, and coffee ground 
vomit. Cachexia usually occurs in older people. In palpable cicatricial 
contraction near the pylorus the differential diagnosis without laparotomy 
is impossible; moreover, cancer may develop on the site of an old ulcer. 
Duodenal ulcer gives about the same symptoms as peptic ulcer. The vio- 
lent pain is often associated with tarry or bloody stools. Occasionally 
there is jaundice. 

Treatment of Gastric and Duodenal Ulcer. — Absolute rest in bed. 

Diet. — Milk, cornstarch pap, slimy gruel, burnt flour soup, tropon 
in peppermint tea, beef jelly, white of egg, custard, water ices, cream, 
and condensed milk. 

In the convalescent period, after four weeks, add scraped beef, sweet- 
breads, and farinaceous puddings. Rectal alimentation may be required. 

Medication. — Bismuth, gr. xxx, t. i. d., with or without opium, or 
morphine subcutaneously, gr. J to ^. 

To check vomiting, cracked ice should be given and small doses of 
opium administered. 

Feeding by gavage may be necessary to overcome vomiting. 

Lavage will check obstinate vomiting. 

Surgical treatment may be necessary in the event of perforation, collapse, 
or peritonitis or for the purpose of excising the ulcer. Before surgical 
interference is attempted, the patient should have the benefit of the doubt 
and undergo antisyphiliiic treatment, inasmuch as syphilis of the stomach 
has received positive recognition post mortem and should not be forgotten 
clinically. 

CANCER OF THE STOMACH 

This is generally primary, but may be secondary to cancer of neighboring 
organs. It is seldom observed before the age of forty and is decidedly a 
disease of old age. At the present time we look upon cancer as of parasitic 
origin, but we have as yet no proofs to that effect. 

Location. — Pylorus, cardia, and small and large curvatures. Metastatic 
propagation to neighboring organs is common. Perforation and peri- 
tonitis may occur. 

Prognosis and Duration. — Cancer is fatal in from one to three years. 

Symptoms and Differential Diagnosis. — The cardinal symptoms are: 
Loss of appetite, dyspepsia, pain, vomiting (coffee grounds), dilatation, 
if at the pylorus^ absence of HCl, presence of lactic acid, tumor, progressive 
emaciation, and anaemia. 

The symptoms will vary according to the location of the lesion. Deg- 
lutition will be difficult in obstruction of the cardia. Cancer of the lesser 
curvature may progress without pain or vomiting. Cancer of the pylorus, 
or large curvature, will give typical symptoms and in many instances a 
palpable tumor. Palpation for tumor or undue resistance of infiltrated 
tissue is unsatisfactory in many instances for various reasons. In doubtful 
cases an examination under narcosis or an exploratory laparotomy is 
indicated. Transillumination and x ray shadowgraphs will aid in diagnosis. 



ILEMORRHAGE FROM THE STOMACH 



281 



Differential Points. — The following conditions may simulate cancer of 
the stomach: Chronic gastritis. No tumor, no vomiting of material like 
coffee grounds. Gastric ulcer, with and without pyloric thickening. Tumor 
rare. HCl in excess. Pernicious ancemia. No tumor, great reduction of 
the red cells. Cancer of the pancreas. No coffee ground vomit, HCl present, 
fat in the stools. Cancer of the colon, and of the duodenum. No coffee ground 
vomit, HCl present. Movable kidney. No coffee ground vomit, no cachexia, 
HCl present, characteristic shape of a palpable tumor. Impacted fceces. 
Disappears under treatment. Cancer of the liver or gall bladder. No coffee 
ground vomit, HCl present. Tumor of the abdominal wall. Extraperitoneal, 
no gastric disorder. Tumor of the omentum (tuberculous or malignant), 
no characteristic gastric symptoms. 

In the presence of so many possibilities an exact diagnosis may require 
weeks of observation unless an exploratory lg,parotomy is performed. 

Treatment. — Operative interference may relieve urgent symptoms, but 
will not cure the patient. Pylorectomy should be performed as early as pos- 
sible. Gastroenterostomy will facilitate the transfer of chyle. Gastrostomy 
will permit the patient to be nourished through a gastric fistula. To relieve 
pain, morphine or chloral hydrate is to be administered. A liquid or soft 
diet will give the least distress, and stomach lavage may afford temporary 
relief. 

SYPHILIS OF THE STOMACH 

This may be of the ulcerative, diffusely sclerotic, or gummatous form. 
Nothing abnormal can be detected on physical examination. Pain and 
vomiting are the only symptoms; therefore the diagnosis rests upon the 
therapeutic test, and the treatment is self evident. 



BENIGN TUMORS OF THE STOMACH 

Tumors, such as polyps, lipomata, myomata, lymphadenomata, cysts, 
gastroliths, and foreign bodies in the stomach have been observed and 
might call for operative measures. 

Non-malignant hypertrophic stenosis of the pylorus may occur in adults 
and infants (see Paediatrics) and give all the symptoms of cancer, except 
vomiting of blood. The benign stricture is recognized as such at the time 
of operative interference. Before operative treatment is carried out the pa- 
tient should undergo antisyphilitic treatment with the hope of overcoming 
a syphilitic tissue hyperplasia, which may involve any organ of a syphilitic 
patient. 

HAEMORRHAGE FROM THE STOMACH 

This ailment in infants is discussed in the Psediatric Section. The blood 
vomited by adults may be red and fluid or like coffee grounds, and 
is often mixed with food. In haemoptysis the blood is bright red and 
frothy and is coughed up. In large haemorrhage into the stomach death 
may take place in a very short space of time, and only an autopsy will 
show the cause. Moderate bleeding from the stomach may be due to various 
causes, viz. : Swallowing of blood from the nasopharynx, injury, vicarious 
menstruation, gastric ulcer, gastric cancer, portal obstruction, hepatic 



282 THE DIGESTIVE SYSTEM 

and cardiac disease, the hssmorrhagic diathesis in acute or chronic illness 
and constitutional disease or haemophilia. 

Prognosis. — Htemorrhage from the stomach is rarely fatal. 

Treatment. — The treatment of haemorrhage from the stomach for the 
time being is symptomatic. It includes absolute rest in bed, an ice bag to 
the stomach, opium by the mouth, ergotine hypodermically (gr. 2 pro dosi), 
also suprarenal extract, ice by the mouth, a ligature around one or two 
extremities, subcutaneous saline infusion in collapse, and surgical measures 
in ulcerative conditions. 



GASTROINTESTINAL NEURALGIA (CARDIALGIA, GASTRALGIA, 
ENTERALGIA, COLIC, "STOMACH CRAMPS") 

Pain in the abdominal region may be purely a neurosis. It may be due 
to overdistention and constipation, or it may be a symptom of organic 
disease, such as cancer, ulcer, intestinal tuberculosis, strangulation, or 
appendicitis, or it may be a familiar manifestation of tabes dorsalis (painful 
crises). The possibility of gallstone, lead, and renal colic in hypogastric 
pain should not be overlooked, particularly in the absence of jaundice, and 
in some cases gastrointestinal adhesions are productive of parox3'^smal 
pain. Uterine and ovarian colic are often called stomachache. Grief, 
worry, overwork, anaemia, malaria, arteriosclerosis (arteriosclerotic belly- 
ache), syphilis, gout, and neurasthenia are predisposing factors in gastro- 
intestinal neuralgia. The pain is of varying character and often accom- 
panied by a feeling of faintness. Cardialgia begins in the epigastrium and 
radiates to the back, especially along the side of the stomach. It may 
last a few minutes or hours. 

Differential Diagnosis. — The following points may be borne in mind: 
Gastric crises of tabes are associated with lancinating pains, Argyll Rob- 
ertson pupil, girdle sensation, and absence of patella reflex. In ulcer 
of the stomach the pain comes on after eating and is confined to certain 
spots in the epigastrium. It is increased by pressure, and may radiate to 
the back. The vomit contains blood and a large amount of free HCl. 
In perigastritis, the sequela of ulcer, pain is not persistent and there is 
no vomiting of blood. In duodenal ulcer vomiting is infrequent. There 
is often blood in the fajces, and occasionally we notice jaundice. In cancer 
of the stomach there are pain and "black vomit." In gallstone colic the pain 
is more apt to radiate to the right shoulder. Frequently we observe jaun- 
dice, and often there is a chill with fever and swollen spleen, and pres- 
sure upward behind the ribs and behind the gall bladder elicits pain. 
The stools may be clay colored. 

In renal colic the pain usually radiates into the pubic region, and the 
urine may show blood and small calculi. 

Lead colic has a history of exposure to lead intoxication and the gums 
show a characteristic discoloration. 

In appendicular colic palpation will find the appendix painful and swollen. 

In mucous colic mucus and fibrinous shreds pass from the bowel. 

Treatment. — When pain is severe the patient should rest in bed. 
If no relief follows the application of a hot water bag or mustard plaster, 



CONSTIPATION; OBSTIPATION; F^CAL IMPACTION 283 

and the administration of hot tea or ten drops of Hoffmann's anodyne on 
sugar, a morphine injection (gr. J to ^) should be given over the seat of 
pain and repeated if necessary. The following medicine is also very prompt 
in checking stomach pain: 

I^ Chloroformi, 5 j ; 

Morph. sulph., gr. j ; 

Pulv. gummi arabici, 5 j ; 

Aquae, ad, 5iij ; 

M.: Ft. emuls. et adde 

Syrupi, 5jv; 

Aq. amygd. amar., 5j- 

S.: 5j every half hour until relieved. 

After the attack of cardialgia is over we should look for the underlying 
cause and endeavor to prevent a recurrence. 

The purely neurotic form of gastralgia is therefore recognized by exclu- 
sion, and for this class of cases a change of scene — outdoor exercise and 
abundant food — nux vomica and hydrochloric acid are indicated. Pain 
in the lower bowel may be eased by suppositories of opium and belladonna. 

INDICATIONS FOR OPERATIONS ON THE STOMACH 

Malignant disease should be operated upon at the earliest possible mo- 
ment. Non-malignant obstruction to the flow of chyle should be operated 
upon, provided a long continued trial of out of door life combined with 
gymnastics and massage (also vibratory massage) and antisyphilitic treat- 
ment has failed to give relief. 

Gastrotomy may be indicated for the purpose of direct inspection, for 
the removal of a foreign body, or for gaining access to a strictured oesopha- 
gus. A gastric fistula (gastrostomy) may be necessary for feeding in stricture 
above the stomach. Gastroenterostomy is indicated in otherwise ''inoper- 
able " strictures of the lower stomach and duodenum and in extreme atonic 
dilatation of the stomach. Resection of the stomach in part is done for the 
removal of diseased stomach tissue. Gastroplication is an operation devised 
for atonic dilatation of the stomach without stricture, after all other means 
have failed. 

CONSTIPATION ; OBSTIPATION ; FyECAL IMPACTION 

Peristalsis carries off at regular intervals the waste products of diges- 
tion. Constipation is the opposite of diarrhoea. Two daily evacuations 
may be normal in some individuals, while others may normally have one 
movement every other day. According to the writer's experience, healthy 
individuals have on an average one movement a day. Retention of faeces 
produces local irritation and undue absorption of putrefactive poisons, 
resulting in malaise, dyspepsia, malnutrition, anaemia, etc. Primary 
anaemia may cause atonic constipation. 

Causes of Constipation. — Congenital malformations or anatomical pecul- 
iarities, benign and malignant strictures of the pylorus, bowel, or rectum, 



284 



THE DIGESTIVE SYSTEM 



loss or excitahility of the mucous lining of the intestine, as in chronic catarrh, 
atrophy and adhesion following peritonitis, etc. 

Degeneration of the nervous apparatus of the intestine is frequently 
called upon to explain constipation, but we have no definite knowledge 
on the subject. It is a fact, however, that constipation is frequently found 
in neurasthenics, melancholies, and persons suffering from diseases of the 
central nervous system. Paresis of a portion of the intestine is occasionally 
productive of constipation. 

A rigid sphincter or anal fissure or painful spasm of the sphincter causes 
constipation. There may be atonic constipation from lack of secretion, 
from anaemia, from organic diseases, and from enteroptosis and flabby 




Fig. 109. — Enteroclysis. 



abdomen, which is common in women. In rhachitis we observe muscular 
atony of the bowel in children. 

We speak of spastic constipation with and without pain in neurasthenia 
and lead poisoning. We observe constipation from lack of moisture or 
lack of fat, or sugar, or from a one-sided diet (no vegetables, salads, or 
fruit), from negligence and irregularity, deferring visits to the closet, from 
lack of exercise and sedentary habits and occupation. 

Constipation may be due to internal or external hernia, to invagination 
and intussusception, and to complete strangulation of the bowel, and in 
extreme cases bile and fsecal matter are vomited. 

Treatment. — Temporary or accidental constipation as caused by a 
change of diet, etc., is overcome by an enema or a laxative drug. In chronic 
constipation we study the underlying cause and treat accordingly. Correct 
any faulty diet; increase vegetables, fruits, fats, liquids. Adults should 



CONSTIPATION; OBSTIPATION; FAECAL IMPACTION 285 

sip slowly J to ^ pint of cold or warm water morning and evening. Inculcate 
regular habits (also in children). Exercise in the fresh air, walking, riding, 
bicycling, tennis, golf, gymnastics, cold sponge bath, and shower baths. 
Massage of the abdomen. Automassage by means of a five to fifteen pound 
cannon ball rolled over the abdomen from right to left may be practised. 
Enemata of soap water by means of a fountain syringe and soft rectal tube 
or a piston syringe with a soft tube are useful, also suppositories of soap, 
glycerin, and gluten, dilatation of a rigid sphincter under narcosis, healing 
of anal fissures, and mineral waters, Vichy, Saratoga, Carlsbad (artificial 
Carlsbad salt in warm water), Hunyadi, Apenta, etc. Laxative drugs: Castor 
oil, croton oil, rhubarb, rhubarb and magnesia, compound rhubarb pills, 
effervescent citrate of magnesium, sulphate of magnesium, senna and 
manna, electuary of senna, compound licorice powder, tamar indien, com- 
pound infusion of senna with sodium sulphate, cascara with and without 
malt, aloes, St. Germain tea, calomel and jalap, podophyllin, strychnine and 
belladonna, lapactic pills, cream of tartar, Eno's fruit salt, iron and arsenic. 
An efficacious aloin pill is thus composed: 



I^ Aloin, 

Extr. nuc. vomic, 
Ferri. sulphat., 
Pulv. myrrhae, 
Pulv. saponis, 



- aa gr. J. 



For spastic constipation warm aromatic high injections with oil are to 
be given. 

Fwcal impaction in the rectum calls for manual aid. Complete obstruc- 
tion demands timely surgical aid. Constipation in infants from lack of 
food (apparent constipation) may be remedied by proper feeding (see 
Paediatrics). 

When laxatives are given for any length of time, nature's remedies, 
exercise and massage, must not be neglected. In extreme cases of atonic 
constipation in children and adults the writer has known ten days to elapse 
before a movement resulted. In chronic constipation of children enemata 
may have to be given once daily for years, together with a laxative drug 
once a week. 

In enteroptosis and constipation an abdominal supporter should be 
worn. 

Stercoral, or faecal, tumors are sometimes mistaken for true tumors 
and are sometimes overlooked. They give rise to various neuralgias by 
pressure on nerves, and frequently a hot burning feeling is complained of 
by the patient which radiates from the seat of the faecal tumor in all 
directions. Persistent high enemas of soap suds and oil will remedy this 
condition. 

Migraine and obstipation offer no uniform picture, but are of frequent 
occurrence. Laxatives, hydrotherapy, and physical and dietetic measures 
are to be employed. 



286 THE DIGESTIVE SYSTEM 



DIARRHCEA AND INCONTINENCE OF F>ECES IN ADULTS 

Diarrhoea is the opposite of constipation, and is usually due to increased 
peristalsis and supersecretion of the intestine. The principal cause of diar- 
rhoea is an abnormal condition of the intestinal contents (spoilt food, gastro- 
enteric infection and intoxication), which may progress from a mild dyspeptic 
diarrhoea to catarrhal or ulcerative enteritis or choleraic diarrhoea. There 
is a psychic form of diarrhoea which does not have its origin in the intestine. 
We are all familiar with the intestinal noises and nervous diarrhoeas of 
neurotic individuals. To this group belong the sudden diarrhoeas of patients 
anticipating or dreading an examination or operation, etc. In all forms 
of diarrhoea the organism must suffer more or less, but a diarrhoea due to 
increased peristalsis of the large intestine (chronic diarrhoea due to rectal 
ulcer) is often tolerated a long time because of lesser absorption in the 
large intestine. 

Diarrhoea may be acute or chronic according to its underlying causes. 
The most common cause is spoilt food (dyspeptic diarrhoea). Catarrhal 
or ulcerative enteritis causes inflammatory diarrhoea. Dyspeptic and 
inflammatory diarrhoea are not to be confounded with the incontinence of 
fceces observed in the typhoid condition or in central nervous disease. 

Clinical Forms of Diarrhcea. — Dyspeptic diarrhoea in children from 
overfeeding or from spoilt food, erroneously attributed to teething (see 
Paediatrics); dyspeptic diarrhoea in adults; acute nervous diarrhoea; 
paroxysmal mucous colitis (membranous diarrhoea) ; chronic nervous 
diarrhoea (as in tabes) ; diarrhoea from catarrhal or ulcerative enteritis 
due to microbial infection, such as cholera asiatica, cholera infantum, 
typhoid, tuberculous, syphilitic, or dysenteric ulcerations; symptomatic 
(dyspeptic) diarrhoea in acute infectious disease, septic conditions, chronic 
malarial disease, cardiac, pulmonary, renal, pancreatic, or hepatic disease, 
etc.; fat diarrhoea in infants and adults in hepatic and pancreatic disease; 
amoebic diarrhoea (so called) in which amoebae are found in the stools; 
and morning diarrhoea, generally due to some organic ailment in the colon 
or rectum. 

General Treatment. — The symptomatic management of diarrhoea in 
adults is exceedingly simple. In the mild forms temporary dieting will suf- 
fice, and we can aid nature by administering a good dose of castor oil to 
eliminate retained putrescible material. The diet should consist of burnt 
flour gruel or slimy soup and some farinaceous water or toast water, mint 
tea, or carbonated water to quench thirst. Should the watery discharges 
continue, the peristaltic sedatives and astringents are indicated. Opium 
may be administered, five to ten drops of the tincture for adults, given 
once or twice, or tannin, gr. v to x, bismuth, gr. x to xx, several times a day. 

The return to the ordinary food must be gradual, and dilute HCl may 
be given to aid digestion. In children and adults flushing of the colon 
may be practised once or twice a day. Abdominal pain may be controlled 
by opium and belladonna suppositories and by applying a moist compress 
or hot water bag to the abdomen. Chronic diarrhoea due to ulceration 
in the lower bowel may require the establishment of a fistula and flushing 
of the bowel from above downward. 



TYMPANITES AND DILATATION OF THE COLON 287 

Diarrhoea secondary to other disease will be managed on the same lines, 
with due regard to the underlying conditions. 

Mucous Diarrhoea, Mucous Colic, Membranous Enteritis. — This ailment 
is looked upon as a neurosis, and it occurs mainly in women of a neuro- 
pathic constitution, particularly in women with large bellies (enteroptosis) 
and rarely in children. Its purely neurotic nature is doubtful because 
mucous colic is often associated with follicular inflammation in the lower 
intestine. It manifests itself by the usual gastrointestinal symptoms, 
great nervous irritability, and painful and paroxysmal passages of mucus 
and membranes from the bowel, the attacks lasting from three to seven 
days. The membranes may be shreddy, ribbon-shaped, cordlike, or cylin- 
drical. Emaciation and loss of strength occur in varying degrees, and 
numerous other conditions may coexist with this trouble. In making the 
diagnosis it is important to know that various substances may simulate 
membranes. 

Treatment. — Liberal mixed food, no liquid diet, out of door exercise, 
cold douches, wearing an abdominal supporter, the hot water bag to the 
abdomen to relieve pain, or an occasional suppository. Morphine injections 
should be given only in severe pain, as neurotics are apt to acquire the 
morphine habit. 

In the intervals between the attacks the patient is to receive every night, 
before going to bed, an enema of warm oil (ten to fifteen ounces), to be 
retained all night if possible. After the first week, the enema may be given 
every other night, and finally only once a week, until five to six months 
have elapsed. The patient should have a movement from the bowels 
every morning, and if necessary an enema of soap water may be given. 

Incontinence of Faeces may be produced by paralysis or destruction of 
the anal sphincter from whatever cause. Sometimes it results from deep 
ulceration, benign or malignant, but more frequently it is the result of 
operations in the lower rectum, especially for fistula, when the sphincter is 
cut obliquely instead of at right angle (Gant). 

Treatment. — We can cure but few cases, yet we are able to make most 
of these sufferers fairly comfortable, so much so that they can go about 
with their fellow men. This is accomplished by (a) plastic operation; (6) 
cauterization. 

Plastic operation for the relief of incontinence resembles the operation 
for the repair of a badly lacerated perinseum. The ends of the muscle must 
be located, freshened, and sutured together with catgut. The operation 
must be repeated until the desired result is obtained. 

Cauterization is best effected by deep burning of the mucosa in one or 
more places with the object of producing artificial stricture. The cauteriza- 
tions should be at least six weeks apart, and should be repeated until 
sufficient contraction occurs to prevent leakage. 

TYMPANITES AND DILATATION OF THE COLON 

Meteorism is associated with many forms of acute and chronic illness and 
may be defined as an inflation of the intestines with gases — the various gases 
which form in the intestines or are swallowed (air) and are absorbed into 



288 THE DIGESTIVE SYSTEM 

the blood or find a ready or natural outlet by the mouth or the anus, pro- 
vided the muscular elements are in good tone. Increased gas production 
lessened absorption, and insufficient expelling power are the causative 
factors of meteorism found in dyspepsia, enteritis, intestinal indigestion, 
typhoid fever peritonitis, obstruction, constipation, hepatic derangements, 
lead colic, rickets, and hysteria. Tympanites may impede the action of 
the diaphragm and heart and cause pain, dyspnoea, and collapse. 

S3miptoms. — The symptoms are distention, a tympanitic percussion 
sound, tenderness, and colic. 

In tympanites from perforation the liver dulness is obliterated. 

Treatment. — (a) Of the underlying cause; (6) Symptomatic. 

Turpentine internally, enemata, hot stupes, and hot peppermint tea 
may be employed, also charcoal, bismuth, hydrochloric acid, ether, opium, 
massage of the abdomen, vibratory massage, and the introduction of a 
rectal tube or puncture of the intestine. In prolonged tympanites an 
out of door life and cold sponge baths are indicated. In colic and tym- 
panites of children from too much milk, dilute the milk. In tympanites 
in typhoid fever, stop the use of milk. 

DILATATION OF THE BOWEL, CONGENITAL AND ACQUIRED 

Dilatation of the bowel may be due to obstruction of the bowel or 
chronic constipation and other causes, and in some instances no organic 
cause can be discovered (idiopathic dilatation). The distention of the 
abdomen and constipation are the most prominent features. The general 
health deteriorates. An autopsy in such cases reveals an enormous enlarge- 
ment of the transverse colon and sigmoid flexure. 

Prognosis. — The prognosis in these cases is unfavorable. Eighteen out 
of twenty-four cases reported are known to have terminated fatally. 

Treatment. — This includes tonic hygienic management, the selection 
of proper food, mild abdominal massage, vibratory massage, laxatives, 
enemata, or suppositories, and the use of a rectal tube to remove the gas. 
In cases which do not improve under such treatment an exploratory 
laparotomy may be indicated. 

^ . 
ACUTE CATARRHAL ENTERITIS 

Acute catarrhal enteritis in adults occurs primarily or is secondary to 
various ailments, and should be looked upon as an infection or intoxication 
due to putrid intestinal contents, decomposed food, or some irritant poison. 
It is a common trouble in hot weather when food is apt to spoil. 

Symptoms. — These are diarrhoea, colicky pain, gurgling noises from 
gases, sometimes vomiting, a furred tongue, thirst, loss of appetite, scanty 
urine, and occasionally fever. The duration is from three to eight days. 

Prognosis. — The prognosis is favorable. In rare instances an apparently 
acute enteritis may develop into peritonitis with effusion, meteorism, and 
a rigid abdomen. Such cases are due to the perforation of a simple or tuber- 
culous ulceration of the intestine or to the breaking up of a degenerated mesen- 
teric gland, or an embolic thrombosis in some mesenteric vessel. 



ACUTE GASTROENTERITIS IN ADULTS; CHOLERA MORBUS 289 

Clinical Varieties. — Duodenitis is sometimes diagnosticated on account 
of the associated jaundice if the small intestine, jejunum and ileum, is the 
seat of inflammation. The stools are flocculent and contain undigested 
food, unchanged bile, and some mucus. 

Colitis is characterized by marked pain, diarrhoea, tenderness over the 
colon, and souplike stools. 

In proctitis, or rectal catairii, there is painful tenesmus with mucus and 
pus in the discharges. 

Treatment. — Rest in bed, evacuation of the bowels by castor oil (5j) 
or a saline cathartic. 

Bland Diet. — Burnt flour soup, slimy soup, Vichy, tea, toast, pepper- 
mint tea with tropon, raw eggs. 

Medication. — Give five drops of dilute hydrochloric acid in water after 
eating. To stop pain, give from five to ten drops of laudanum. To check 
persistent diarrhoea, order ten grains of tannin or tannigen, with or without 
half a grain of opium, or this prescription: 

I^ Bismuth, subnitrat., gr. xx; 

Pulv. opii, gr. ss. 

M. S.: One such powder twice a day. 

To aid nature in eliminating foul material^we employ flushing of the 
bowels once or twice a day. (See General Therapeutics.) 



ACUTE GASTROENTERITIS IN ADULTS; CHOLERA MORBUS 

This is a common disorder in hot weather, and is to be classed as an 
infection or intoxication due to putrid or poisonous gastrointestinal contents 
and spoilt food and drink, such as canned goods, fish, shell fish, ice cream, 
milk, etc. 

Symptoms. — The symptoms are the same as in acute enteritis, but in 
addition there is vomiting on account of the participation of the stomach. 

Treatment. — As the physician is generally called after vomiting has 
set in, an emetic is seldom necessary. In some cases stomach washing will 
be indicated. The patient should rest in a cool room with an ice bag to 
the head, should have ice to quench thirst and subdue nausea and vomiting, 
and should not partake of food for the time being. Internally we give: 

I^ Tinct. valer. seth.,, \ 

Solut. morph. magend., \ aa, 5 j- 

Aquse amygd. amar., ) 
M. S.: Fifteen drops, in ice cold carbonated water, every hour 
until relieved. 

Lavage of the bowel will aid nature in eliminating foul material. 

Diet. — For the first and second days the diet will be the bland one 
mentioned above. When the patient is fully convalescent, he can return 
to the ordinary food. 

Prognosis. — The prognosis is favorable except in old and feeble people 
and infants, who sometimes die in collapse. 



290 THE DIGESTIVE SYSTEM 

CHRONIC ENTERITIS 

This is usually a sequel of repeated attacks of acute enteritis or dysen- 
tery, but it may develop in consequence of obstruction to the portal 
circulation in chronic hepatic or cardiac disease and chronic malarial 
disease, etc. 

Symptoms. — Diarrhoea is present, or diarrhoea alternating with constipa- 
tion. The pain is not so severe as in the acute form. Mucus and undigested 
food are passed in the stools. 

Differential Points. — An ailment running a course as a chronic enteritis 
may have for its underlying cause syphilis, tuberculous ulceration of the 
intestine, or tuberculosis of the peritonaeum. A careful clinical investiga- 
tion will finally locate the trouble. This involves, besides the usual inquiries, 
an examination of the stools, an examination per rectum, a record of the 
temperature for two weeks, and an examination of the blood. 

Treatment. — The underlying cause must be treated in the first place. 
Rest in bed, a bland restricted diet (including gum arable mucilage), and 
intestinal flushing are indicated. In malarial subjects quinine must be 
used; in syphilitic subjects, antisyphilitic treatment is indicated; in tuber- 
culous subjects, an out of door life is demanded. When tuberculosis of 
the peritonaeum is suspected, an exploratory laparotomy may furnish us a 
positive diagnosis and afford relief and cure to the patient if the tuberculous 
infection is not a general one. The symptomatic medication in chronic en- 
teritis is with bismuth, tannin, and opium. If a local examination should 
show accessible ulceration in the lower intestine, local applications of silver 
nitrate are useful, followed by extract of opium (gr. ss) and extract of bel- 
ladonna (gr. ss) suppositories. In otherwise incurable cases the intestine 
may be flushed from above downward by establishing a fistulous opening 
in the right flank. 

DYSENTERY IN ADULTS 

When an infection is localized in the lower bowel and is intense enough 
to produce much local inflammation, diarrhoea, fever, tenesmus with mucus, 
blood, and the passage of fibrinous membranes, we speak of membranous 
enteritis, or dysentery, which may occur sporadically or in epidemics. As 
dysentery is transmissible like typhoid fever, the patient should be isola^ted 
and the stools disinfected with lime or copperas. 

Clinical Varieties. — 1. Catarrhal dysentery. Duration about one week. 

2. Amoebic, or tropical, dysentery. The amoebae are found in the 
stools and there is a steady loss of strength and weight. Uncomplicated 
cases last from six to twelve weeks, with a tendency to become chronic 
and with hepatic abscess following. 

3. Chronic dysentery. ^Distinguished from other forms of chronic 
diarrhoea by the tenesmus and bloody, mucoid stools. 

Prognosis. — In the mild forms, recovery is the rule. The mortality 
varies according to the nature of the lesion and the vitality of the sufferer. 

Treatment. — Rest in bed, a bland diet (see Diarrhoea), flushing of the 
bowels, simple and medicated, suppositories of extract of opium, gr. ^, to 
overcome pain and tenesmus, astringent medication. 



INTESTINAL ULCER 291 

The treatment and diet are practically the same as in catarrhal enteritis, 
but the local management is more energetic. Irrigation of the bowels must 
be practised two or three times a day. For irrigating we use boiled water, 
aromatic water (mint decoction), starch water, with or without opium, 
tannin water (5 to 1,000), alum water (5 to 1,000), ichthyol water, 1 per 
cent, or nitrate of silver solution, 5j to a quart. 

Quinine in watery solution, 1 to 1,000, is employed in amoebic dysentery. 
Astringent internal medication is not to be used in the acute stage, but is 
efficacious in the convalescent stage. 

Bismuth subnitrat., gr. x to xxx, may be given three times a day, or 
tannin, gr. v to x, at the same intervals. 

I^ Plumb, acet. , gr. ii j ; 

Pulv. opii. gr. ss. 

Such a powder to be given three times a day. In some cases a daily 
dose of half an ounce of castor oil with ten drops of tincture of opium is fol- 
lowed by a cure. 

INTESTINAL ULCER 

Causes. — Ulceration in the intestines may result from a variety of 
causes, viz. : Injury, ulceration in enteritis, acute and chronic, in tuberculosis, 




Fig. 110. — Tuberculous Ulcer of the Ileum. (NicoU, Archives of Paediatrics.) 

in syphilis, in cancer, in typhoid fever (see Typhoid Fever), in thrombosis 
and embolism in heart disease and pyaemia, in stercoral ulcers from the 
pressure of hard faecal masses, and by pressure and perforation from without 
inward. Duodenal ulcers have been observed in infants and adults. 

Symptoms. — Diarrhoea, bloody and tarry stools, pus and tissue, shreds 
in stools, colicky pain, and perforative peritonitis. 
20 



292 THE DIGEvSTIVE SYSTEM 

Diagnosis. — The differential diagnosis involves a lucid anamnesis and 
painstaking examination of the stools and of the lower intestine by means 
of the Kelly tube, if necessary under narcosis. 

Prognosis. — The prognosis depends upon the underlying cause. 

Treatment. — The treatment is specific, surgical, or palliative, according 
to the underlying condition. The diet, hygiene, and internal and local 
medication are discussed under Diarrhoea and Enteritis. The specific treat- 
ment involves an inunction cure (mercurial ointment) or mercury and iodide 
of potassium internally. The surgical treatment involves flushing of the 
bowel through a fistula established m the colon on the right or left side. 

TUBERCULOSIS OF THE INTESTINE 

This may be primary, but is usually secondary to pulmonary tuberculosis. 
As such, it is a fatal complication for which there is only palliative or 
symptomatic management. 

APPENDICITIS 

Diagnostic Palpation of the Appendix Vermifonnis 

In searching for the appendix the author adheres to the rules laid 
down by Dr. G. M. Edebohls, of New York, as follows: 

"The examiner, standing at the patient's right, begins the search for 
the appendix by applying two, three, or four fingers of his right hand, 
palmar surface downward, almost flat upon the abdomen, at or near the 
umbilicus. While now he draws the examining fingers over the abdomen 
in a straight line from the umbilicus to the anterior superior spine of the 
right ilium, he notices successively the character of the various structures 
as they come beneath and escape from the fingers passing over them. 
In doing this the pressure exerted must be deep enough to recognize distinctly, 
along the whole route traversed by the examining fingers, the resistant surfaces 
of the posterior abdominal wall and of the pelvic brim. Only in this way 
can we positively feel the normal or the slightly enlarged appendix ; pressure 
short of this must necessarily fail. 

"Palpation with pressure short of reaching the posterior wall fails 
to give us any information of value; the soft and yielding structures simply 
glide away from the approaching finder. When, however, these same struc- 
tures are compressed between the posterior abdominal wall and the examin- 
ing fingers, they are recognized with a fair degree of distinctness. Pressuri 
deep enough to recognize distinctly the posterior abdominal wall, the pelvic brim, 
and the structures lying between them and the examining finger forms the 
whole secret of success in the practice of palpation of the vermiform appendix. 

" Proceeding in this manner, the appendix is recognized as a more or 
less flattened, ribbon-shaped structure when quite normal, or as a more 
or less rounded and firm organ, of varying diameter, when its walls have 
been thickened by past or present inflammation. When it is the seat 
of inflammatory changes, the appendix vermiformis is always more or less 
sensitive on pressure; the normal appendix exhibits no special sensitive- 
ness on being squeezed. 

"There are two useful landmarks in practising palpation of the vermi- 



APPENDICITIS 293 

form appendix : McBurney's point and the line of the right iliac arteries. 
The origin of the appendix from the caecum, whatever course its continuation 
may run, is almost uniformly at McBurney's point; hence the diagnostic 
value in appendicitis of pressure over this point. The iliac arteries are 
useful in a twofold way: firstly, because to feel their pulsation distinctly 
means that the fingers have reached the posterior abdominal wall; and 
secondly, because the normal appendix is very constantly found about a 
finger's breadth outside of the artery, on a line between the umbilicus 
and the anterior superior spine of the right ilium. 

"A good guide in searching for the appendix is formed by the right 
common and external iliac arteries, the pulsation of which can be easily 
and plainly felt. The line of these vessels corresponds to a surface line 
drawn from the left of the umbilicus to the middle of Poupart's ligament. 
The appendix is generally found almost immediately outside of these 
vessels. At its base it is separated from the vessels by a space of from 
one half to one inch, while lower down in its course it generally crosses very 
obliquely the line of the arteries. 

"Theoretically, two conditions mainly militate against the successful 
palpation of the appendix vermiformis after the method above described; 
practically, the difficulties offered by these two conditions amount to very 
little or nothing. I refer to the variable location of the appendix and to 
the fact of its common deep situation behind the caecum. 

" With the very rare exceptions of its situation far away from its usual 
site, the origin of the appendix vermiformis is practically always found at 
what is known as McBurney's point. In fact, it is this constancy of the 
situation of the appendix which gives its practical value to McBurney's 
point in the diagnosis of appendicitis. The tenderness elicited by extremely 
localized pressure at McBurney's point is due to the presence beneath the 
finger of the inflamed appendix." 

Definition and Varieties. — Appendicitis is a disease of the vermiform 
appendix with catarrhal, ulcerative, perforative, and gangrenous stages. 
The clinical varieties are the acute cases and the chronic recurrent cases. 
Infection, tumefaction, and various degrees of strangulation of the appen- 
dicular blind sac appear to be the pathological explanation of appendicitis. 
In some families there is an hereditary predisposition to appendicitis. 
Edebohls maintains that chronic appendicitis is the chief symptom and 
most important complication of movable right kidney. 

S3rmptoms of Acute Appendicitis. — Acute pain in the right lower abdo- 
men which may radiate in various directions; pronounced tenderness in the 
right iliac fossa. McBurney's point (the centre of a line drawn from the 
anterior superior spinous process to the navel), pronounced tenderness of 
the appendix as elicited by palpation, nausea, vomiting, fever, accelerated 
pulse. Diarrhoea or constipation may be present. Leucocytosis is a fairly 
constant symptom. Suppuration is provable by an exacerbation of previous 
symptoms and increase in size of the tumor or swelling located at 
McBurney's point or in the lumbar region or elsewhere. Perforation of the 
appendix may be indicated by severe pain, great tenderness, and marked 
rigidity. Pronounced sepsis may be inferred from vomiting and rapid 
pulse and high fever. 



294 THE DIGESTIVE SYSTEM 

Differential Points. — In renal colic and twists of the ureter the pain 
radiates into the groin and testicle, and there is haematuria or hsemo- 
globinuria. Pain in the groin and testicle is sometimes observed in appen- 
dicitis. The urine should be examined for small calculi. 

Indigestion and Enterocolitis. — No circumscribed tenderness. No rigidity. 
No tumor. No tenderness of the appendix on palpation. 

Intestinal Obstruction. — Palpation of the appendix is negative. 

Acute Cholecystitis or Hepatic Abscess. — Tenderness on pressure from 
below the margin of the ribs upward. No tenderness of the appendix on 
palpation. 

Gallstone Colic. — Pain radiates to the back on the right side, and the 
appendix is free on palpation. 

^ Salpingitis, oophoritis, and ectopic gestation are recognized by bimanual 
palpation of the pelvic organs, and the latter is denoted by menstrual 
irregularities. 

Perinephritic abscess on the right side may arise from appendicitis, 
but is usually a complication following an operation for appendicitis. If 
it is independent of appendicitis, the appendix is not tender on touch. 

Tuberculous peritonitis is a slow process; palpation of the appendix 
may be impossible. 

Mucous colic gives its own characteristic symptoms, and the appendix 
is found to be free on palpation. 

Coxitis. — In young children appendicitis has been mistaken for hip 
joint disease. As the appendix can readily be palpated in children, the 
differential diagnosis is not difficult. 

Acute rheumatic myositis of the rectus abdominis muscle simulates appen- 
dicitis. 

Typhoid fever is usually associated with right iliac tenderness. The 
Widal serum test will settle the diagnosis in most cases. In typhoid fever 
the onset is slow and roseola is generally observed. Seibert, of New York, 
has reported two cases of typhoid fever combined with appendicitis. 

Influenza, pleurisy, pneumonia, malarial disease, herpes zoster of the 
twelfth intercostal nerve, and other infections which frequently begin with 
severe gastrointestinal symptoms cannot be mistaken for appendicitis 
by any one who has learned to palpate the appendix. 

The prognosis is uncertain. Mild cases end in recovery, as do localized 
abscesses after an operation. Severe septic peritonitis cases will often 
prove fatal with or without an operation. We are unable to judge of the 
clinical severity of a case before an operation, and we are unable to give a 
reliable prognosis, and physician and surgeon therefore should co-operate 
in the management of a case. 

Treatment. — General Indications for Operation: 

1. In cases of diffuse perforative appendicitis an immediate operation is 
mdicated. Exceptionally patients get well without an operation. 

2. In cases of acute appendicitis the patients always need careful observa- 
tion. If the pulse has the tendency to stay high, the indication for an oper- 
ation is given. 

3. In mild cases, when the patients are doing well, wait for the sub- 
sidence of symptoms and operate in the interval. 



BENIGN AND MALIGNANT NEOPLASMS OF THE INTESTINE 295 

4. In case of doubt, the operation is better than waiting. After the 
first attack from which the patient recovers without an immediate operation 
the appendix should be removed. The appendix, once inflamed, must be 
looked upon as a diseased organ which is very apt to give repeated and 
more serious, even fatal trouble in the future. Chronic appendicitis is 
to be diagnosticated, not on subjective symptoms, but on objective signs. 
Unless, in cases of suspected chronic appendicitis, the surgeon can recognize 
by palpation the thickened appendix and limit tenderness on pressure to 
the diseased organ, he will not be justified in operating. One broad rule 
governing the question of operative interference in appendicitis should be, 
not to operate in chronic cases unless you can feel the diseased appendix, 
nor in acute cases unless by palpation you can recognize either the diseased 
appendix or the presence of a tumor. Anaesthesia may be necessary. In 
exceptional instances, to decide the question. 

The gravest complications following appendicitis are septic peritonitis 
and septic thrombosis of the portal vein. The latter is almost invariably 
fatal and may be recognized by fever, chills, sweating, rapid action of the 
heart, and local tenderness. 

Non-operative Treatment. — If in a given case of appendicitis an 
immediate operation is not decided upon, the management is symptomatic, 
as follows: Rest in bed, an ice bag or hot water bag to the abdomen, liquid 
diet, a small enema of warm soap water or oil each day or castor oil in- 
ternally, and, to aid digestion, 5 to 10 drops of dilute hydrochloric acid, to 
be given in water after each feeding. It is not wise to mask the clinical 
picture by giving morphine or opium. When pus formation is evident, and 
an operation has been decided upon, the patient can be made comfortable 
by morphine subcutaneously. When the pain is quite severe and the pulse 
and temperature are not high, and it has been decided not to operate 
during the first attack, an injection of morphine may also be indicated. 

BENIGN AND MALIGNANT NEOPLASMS OF THE INTESTINE 
Diagnosis. — The diagnosis oi carcinoma rests on the following points: 
The age of the patient, usually over fifty years, a palpable tumor, progressive 
anaemia and cachexia, signs of obstruction or disturbed bowel action, 
colicky pain and vomiting, the presence of blood, pus, and shreds in the 
stools, secondary deposits in the liver, lungs, and mammae, and such other 
symptoms as may be inferred when the kidney or ureters are involved or 
perforation, fistulae, and general peritonitis are present. 

Differential Points. — Carcinoma of the rectum may be mistaken for 
chronic dysentery or non-malignant stricture, and vice versa. A tumor 
due to foBcal impaction can be indented. Cysts and tuberculosis of the peri- 
tonoBum or mesentery may simulate a cancerous tumor. Movable kidney 
and chronic appendicitis have been taken for cancer of the intestine. 
Cancer of the pancreas, of the pylorus, and of the gall bladder may simulate 
cancer of the intestine. Benign tumors have been observed and mistaken 
for cancer of the intestine. In all such obscure conditions the proper 
procedure is exploratory laparotomy with immediate extirpation and 
intestinal anastomosis if feasible. If the case is found to be "inoperable " 
X ray treatment is indicated. 



296 THE DIGESTIVE SYSTEM 



INTESTINAL OBSTRUCTION, ACUTE AND CHRONIC 

Symptoms. — The cardinal symptoms of intestinal obstruction are acute 
and severe pain (sometimes absent), no movement or passage of flatus 
from the bowels, vomiting (gastric, bilious, or faical), tympanitic distention 
of the abdomen, usually no fever, prostration and collapse in the termi- 
nal stage. 

The Site of the Obstruction. — If the obstruction is high up, there is 
less abdominal distention than in obstruction of the colon; if in the lower 
bowel, there may be tenesmus and the passage of bloody mucus. Abdominal 
palpation and bimanual palpation externally and through rectum or vagina 
may reveal a tumor or swelling. On various occasions the writer has 
been able to detect the site of the obstruction by noting where the tympa- 
nitic percussion sound of distended intestine merged into dulness over a 
collapsed area of intestine. 

Invagination, or intussusception, of the intestine may be ileocaecal, ileo- 
colic, or colicorectal. In infants and young adults the onset is more or 
less acute, with tenesmus, mucus, and blood. Occasionally a sausage- 
shaped tumor can be felt. 

Differential Points. — Volvulus, or twist of an intestine, is usually located 
in the large intestine or the sigmoid flexure, and gives no distinctive symp- 
toms apart from those already enumerated. 

Fcecal obstruction is usually chronic, with a history of constipation. 
Indentible fajcal masses can sometimes be felt. 

Strangulation is usually through adhesions and narrow natural slits 
(foramen of Winslow, diaphragmatic hernia, and incarcerated hernia). 
A palpable tumor is rare in cases of strangulation. 

Gallstone obstruction of the intestine is usually intermittent. 

Stricture of the intestine from idceration is seldom recognized before 
opening the abdomen, unless it is situated in the anal region. 

Stricture of the intestine from a malignxint or benign tumor cannot be 
recognized in a tympanitic abdomen. 

Paresis of the intestine and obstruction sometimes follow abdominal 
section or peritonitis, and has been observed in neurotic constipated 
children. On auscultation the intestinal sounds are absent. Other rare 
causes of obstruction can only be conjectured. 

In enteritis and diffuse peritonitis with obstruction there is generally 
a rise of temperature. 

In hepatic colic and obstruction the pain is localized and characteristic, 
and jaundice is often present. 

In renal colic and obstruction the urine shows haematuria or haemoglobi 
nuria. 

Treatment. — The treatment of bowel obstruction is by high enemata 
and inflation, in the dorsal or knee-elbow or inverted position, by means 
of soap water (soft rectal tube); oil with the soft rectal tube; air with the 
soft catheter, bicycle pump, or hand bellows, or carbonic acid gas (inverted 
siphon) . 

The best guide to the amount which has been introduced is tension of 
the abdominal walls. A thorough trial should occupy fifteen to thirty 



REMARKS ON STRANGULATED HERNIA AND TAXIS 297 

minutes, and it may be repeated in an hour. It may be done under narcosis. 
Gentle manipulation through the abdominal wall is permissible. 

If after two or three trials there is no improvement, an operation should 
not be delayed for more than three or four hours. In cases not acute, where 
several days have passed without symptoms of strangulation, laparotomy 
may be delayed longer and further attempts at reduction are proper. The 
writer has observed paretic and pronounced obstipation in a girl of nine 
years, lasting eleven days, with complete recovery. In ileus injections of 
atropine sulphate may be tried. 

Cathartics are contraindicated as soon as the diagnosis of complete 
obstruction is made. Opium or morphine may be administered, to quiet 
pain. 

HAEMORRHAGE FROM THE INTESTINES 

Causes. — Ha?niorrhage from the intestines may result from a variety 
of causes, such as'dysentery, typhoid ulcer, malignant disease, the hsemor- 
rhagic diathesis, acute and chronic, congestion in the portal circulation, 
a foreign body, simple ulcer, tuberculous or syphilitic ulcer, aneurysm, 
haemorrhoids, vicarious menstruation, haemorrhage from above the intestine, 
and swallowed blood. In bleeding from the intestines all these possi- 
bilities must be borne in mind, an exact diagnosis being arrived at by 
exclusion. 

- Treatment. — Rest, fluid diet, opium and acetate of lead internally, 
an ice bag to the abdomen, strychnine, and suprarenal extract. Haemor- 
rhage of the lower intestine may be controlled to a certain extent by means 
of clysmata of cold water, 1 quart; or alum water, 5ij ad Oij; or tannin 
in water, 5j ad Oij; or by means of a tampon or the actual cautery. 

REMARKS ON STRANGULATED HERNIA AND TAXIS 

Definition. — An incarcerated hernia is one in which the bowel contents 
cannot escape, but in which the blood circulation is not cut off. A strangu- 
lated hernia is one in which the constriction is sufficient to shut off the 
circulation of the blood. 

Symptoms. — The symptoms are the logical result of the conditions pro- 
ducing them and are sufficiently characteristic to allow us to form a diagnosis 
by a discrimination between functional constipation and abdominal shock 
with obstruction. 

Pain. This comes suddenly, is severe, is at first localized, and becomes 
general over the abdomen. Sudden cessation of local pain without re- 
duction of the hernia is a grave indication of gangrene. 

Obstipation is pronounced throughout, but the lower bowel may empty 
itself, after which there will be no passage of gas or faeces. 

Tympanites will increase until relief is offered. 

Vomiting is early and persistent and eventually becomes stercoraceous. 

The pulse is accelerated and becomes irregular, small, and thready. 

The temperature may be subnormal in shock and collapse, and may be 
elevated from systemic intoxication. 

The local symptoms are those of inflammation — swelling, heat, redness, 
pain, and tenderness. The face is pinched, drawn, and anxious. 



298 



THE DIGESTIVE SYSTEM 



Treatment. — The treatment for strangulated hernia is by operation. 
Before we cut down upon the strangulating structures it may be justifiable 




Fig. 111. 



-Represents a Properly Applied Truss for the Retension 
OF Double Inguinal Hernia. 



The frame is of German silver covered by hard rubber, with pads of the latter substance. 



to place the patient in a position which may favor spontaneous reduction 
and apply an ice poultice to the seat of the trouble, and to employ gentle 
taxis with or without anaesthesia, with the hope of reducing the hernia. 
FaiHng in this after one or two trials, the use of the knife is indicated. 

To wait for fsecal vomiting or until the patient 
is exhausted is inexcusable. 

Clinical Varieties. — Inguinal hernia (com- 
plete or incomplete), femoral hernia, umbilical 
hernia, ventral hernia, congenital hernia, dia- 
phragmatic and other internal hernias. 

Regarding the question, "Does hernia 
exist?" it may be safely stated that reducible 
tumors in the region where hernias are found 
are generally hernia. 

Dr. W. B. Degarmo's definition of a good 
truss: A well fitting truss is one which retains 
the protruding viscera within the abdomen and 
has its springs so shaped to the body that it 
will remain constantly in place no matter what 
position the body assumes. 




INTESTINAL PARASITES 

Common Forms. — The cylindrical worm 

{^Ascaris lumbricoides) , the thread worm (Ox- 

yuris vermiciUaris) , the tapeworm (Tcenia 

saginata or mediocanellata, the beef tapeworm, sucking disks without 

booklets; Tcenia solium, pork tapeworm. The head has booklets). 



Fig. 112. — Skein of 
Worsted Truss. 



INTESTINAL PARASITES 299 

These species of worm are found in the adult as well as in the child. 
In America we generally see the beef tapeworm. The Tcenia solium is the 
common tapeworm of Europe. When the mature proglottides are eaten 
by cattle, the ova wander into various tissues and become encysted as 
cysticerci. 

Treatment. — The cylindrical worm is driven out by the administration 
of santonin, gr. j to ij, ter in die, and saline laxatives. 

The thread tvorm is removed by enemata of garlic boiled in milk. 

The tapeworm in man flourishes in the small intestine, and the only 
certain indication of its existence is the passage of links or sections with 
the stools. Give a saline laxative twenty-four hours before giving the 
following remedy: 

No. 1. 

I^ Oleoresin of male fern, 5iij; 

Ext. kamalse fl., 5ij; 

Chloroform, gtt. x; 

Croton oil, gtt. ij ; 

Castor oil, qs. ad, 5ij- 

M. S.: Give in two doses, one half at 7, the remainder at 9 a. m. 

The patient should eat little between the saline and the remedy. 

Or give No. 2. 

I^ Pelletierine tannate, gr. jv; 

Oleoresin of male fern, tt[xxx; 

Chloroform, f^,y; 

Syrup, 5j. 

M. S.: Take in one dose after a saline laxative, fasting in the 
mean time. 

Give a tablespoonful of castor oil two hours after the remedy has been 
taken. 

Should the worm not be expelled, the remedy can be given a second 
trial after a week of preliminary medication, as follows: 

I^ Spt. terebinth., 1 __ ^.. 

Tinct. valerian aeth., j ' 

M. S. : Ten drops on sugar four times a day. 

During this week the patient should frequently eat pumpkin seed and 
herring salad, also strawberries if they are in season. 

A good tapeworm remedy in capsules is for sale in the shops under the 
name of Dietrich's tapeworm remedy. 

Rare Forms : Ankylostomiasis Hook Worm Disease. — Dr. R. T. Hewlett, 
in the Practitioner for November, 1904, writes: 

"Ankylostomiasis, the condition resulting from the presence of the 
intestinal worm, the Ankylostomum, or, as it is now termed, the Uncinaria, 
is a disease of very wide distribution, occurring over something like three 
fifths of the habitable globe. Attention has recently been specially directed 
to it from its occurrence in the Dalcoath Mine, Cornwall. In America it is 
widely spread, but the parasite here, the Uncinaria americana (Stiles), 



300 THE DIGESTIVE SYSTEM 

is a different species from that of the old world. The chief difference 
between the U. duodenalis and the U. americana are the replacement of 
two of the ventral recurved clawlike hooks of the buccal orifice of the former 
by a pair of semilunar plates, and by the egg of the latter being larger than 
that of the former. The larva?, v»^hich develop in mud from the ova voided 
in the excreta, enter the body either by the mouth or through the skin 
without perceptible lesion. From the skin they pass into the lymph or 
blood vessels, are swept into the general circulation, and eventually reach 
the lungs, whence they pass from the blood vessels into the pulmonary 
alveoli. From the time the larvae perforate the skin until they reach the 
lungs, they remain of the same size; but as soon as they reach the air 
vesicles they begin to grow rapidly. They pass into the bronchioles, up 
the bronchi and trachea, and, emerging through the glottis, pass down the 
oesophagus to the duodenum, where they become sexually mature. In 
order, therefore, to prevent infection, it is necessary, not only to safeguard 
the food, but also to protect the bare skin. 

'' The drugs of value in the treatment of ankylostomiasis are thymol and 
male fern. According to Lutz, 'after a light meal at 11 a.m., give calomel, 
0.5 gramme, and powdered senna, 2 grammes, divided into four doses, one 
hour apart. The last dose may be omitted if sufficient action is secured 
by the three others, and if the full amount does not accomplish its end, 
more senna should be given; after this nutritious and easily digested liquid 
food is the proper diet. This insures liquid evacuations, after which thymol 
is given in 5 to 15 grain doses, in capsule, at intervals of four hours, until 
four capsules are taken, after which a dose of Epsom salts is given." 

Anguillula intestinalis is the name of a parasite found in the stools in 
cases of colicky diarrhoea of the Asiatic zone. In the treatment, thymol and 
male fern are advised to be given internally. 

Amoeba Intestinalis. — (See also Amoebic Diarrhoea.) 

1. The intestine of man may be infected with two varieties of amcebas, 
one pathogenic (Entamoeba dysenterice) , and the other non-pathogenic {En- 
tamoeba coli). 

2. Entamoeba coli, the non-pathogenic variety, is found in 65 per cent of 
the healthy individuals studied, and in 50 per cent of individuals suffering from 
diseases other than dysentery, if a saline cathartic has been administered. 

3. These organisms can be easily distinguished in both fresh and 
stained specimens. 

4. They differ widely in their method of reproduction, and this is the 
most important method of distinguishing them. — C. F. Craig, M.D. 

ENTEROPTOSIS; SPLANCHNOPTOSIS; GLENARD'S DISEASE 

Definition. — A general term applied to a falling or dropping of the 
abdominal viscera due to inherent or acquired weakness of the tissues. 

C. Schwerdt, of Gotha, Germany, has reported ninety-five cases (eighty- 
nine in women, six in men). In sixty-nine cases the stomach was dis- 
placed (?) or atonic; in eighty-six cases the right kidney was movable. 
The liver and spleen play but a rare part in this condition. 

Clinical Features. — The clinical features of enteroptosis are a sense of 
fulness in the epigastrium, nausea, eructations, vomiting, obstinate con- 



INTESTINAL PUTREFACTION AND TOXEMIA 



301 



stipation, abdominal distention, and colic, and in more marked cases pain 
in the back and polyuria, and often in cases yet further advanced pain in 
the diaphragm, palpitation, dyspnoea, sleeplessness, mental depression, 
and melanchoHa — a cHnical picture so often spoken of as " purely functional " 
or "neurasthenic," but which may be referred, with some show of reason, 
to a condition of "anatomical changes " existing and demonstrable. 

The essential element productive of this dislocation is possibly a lessened 
intraabdominal pressure which has its origin in a lax, atonic anterior ab- 
dominal wall. Such a condition exposes the hollow organs, otherwise 
supported, to the influence of gravity 
when filled with their normal contents, 
and one part after the other tends to 
fall, pulling other parts with it. 

The essence of the disease is to be 
sought for in the atonic and enervated 
condition of the nervous system. Pre- 
disposing factors are heredity, methods 
of living, all chronic diseases, the corset, 
and insufficient care during pregnancy 
and after. From this the conclusion is 
drawn that it is purely a constitutional 
disease. The anatomist, the patholog- 
ical anatomist, and the clinician are, 
unfortunately, not in accord in deter- 
mining what is normal and what is 
pathological in the position of various 
abdominal organs, and particularly the 
stomach. 

Treatment. — The wearing of a well 
fitting plain abdominal support (without 

special pads for the support of special organs) is the proper treatment for 
enteroptosis. Regulation of the bowels and the cool douche to. overcome 
"nervousness " give satisfactory results. In some instances it will be nec- 
essary to fasten a wandering kidney, which may be the source of annoying 
reflex symptoms. Dr. A. Rose improvises an adhesive plaster support for 
enteroptosis. 




Fig. 113. — Abdominal Support, Plas- 
ter AND Webbing (Dr. B. Schmitz). 



INTESTINAL PUTREFACTION AND TOXAEMIA; AUTOINFECTION FROM 
THE INTESTINES; INTESTINAL ANTISEPSIS 

When fermentative changes in the gastrointestinal tract proceed beyond 
a certain point, they become a menace to comfort and health. Some 
persons experience little discomfort; others suffer severely. 

Amylaceous Fermentative Dyspepsia produces acetic, lactic, butjTic, and 
other acids and carbonic acid and other gases, giving rise to distention, pain, 
soreness of the abdomen, acid urine, divers neuralgias, hemicrania, and inter- 
costal neuralgia, with and without constipation or diarrhcea, vertigo, etc. 

Putrid Proteid Fermentation produces sulphuretted hydrogen, carbonic 
acid gas, and aromatic bodies, such as indol,skatol, and ptomaines or toxines, 



302 THE DIGESTIVE SYSTEM 

giving rise to malaise, fever, nervous depression, sleeplessness, melancholia, 
headache, vertigo, hemicrania, anorexia, or urticaria. 

The gases formed provoke pain by distention, and the organic acids 
interfere with normal digestion and irritate the mucosa of the intestine 
(catarrhal inflammation of the intestine in children who eat too much 
candy). 

The gases in both varieties may cause dyspnoea and suggest heart lesions 
and asthma (asthma dyspepticum). 

Intestinal putrefaction in infants may give rise to very high temperatures 
and convulsions, and an early recognition is of prime importance. In 
renal, hepatic, and cardiac disease intestinal fermentation is a serious 
complication, and the great value of laxatives is obvious. Undue intestinal 
fermentation is also seen in anaemia, chlorosis, and leucaemia — in fact, 
anaemia and hsemorrhagic phenomena may result from intestinal fermenta- 
tion. Epileptoid seizures and possibly chorea are caused by intestinal 
indigestion. In the present state of our knowledge scurvy must be looked 
upon as a chronic ptomaine poisoning from prolonged intestinal putrefaction. 
In all such cases the ethereal sulphates are found in the urine. As a prac- 
tical test, the test for indoxyl in the urine is here given : Mix equal quantities 
of urine and strong HCl. Add a drop or two of freshly prepared chlorinated 
lime and a small quantity of chloroform, and shake. The indoxyl present 
will be converted into indigo blue by the chlorinated lime and show a blue 
color in the layer of chloroform. This is of value as a chemical test. 

Management of Intestinal Fermentation. — Sufferers from autoinfection 
must take only perfectly sound food and such articles as are least apt to 
become the source of putrid fermentation within the intestines. Persons 
who are liable to "bilious attacks " and attacks of "sick headache " or 
dyspeptic vertigo must be careful in indulging in the pleasures of the table, 
and avoid late dinners with wine and rich food. Children should not be 
allowed to have much cake or candy, and must avoid unripe or overripe 
and spoilt fruit. The management of indigestion in infants is discussed in 
the paediatric section of this book. 

Diet in Intestinal Indigestion. — No inflexible rule of diet can be 
given. Fresh bread, sweets, rich pastry, leguminous foods, cabbage, dense 
cheese, mayonnaise, beer, and sweet drinks increase flatulence and must be 
avoided. Milk is well borne by some and not by others. Stewed fruit is 
usually well tolerated. Smoking may have to be stopped for a time. In 
some instances a change to a vegetarian diet is followed by marked 
improvement. 

Exercise is a desideratum, such as walking, bicycling, rowing, riding, 
exercise with the punching bag, and gymnastics. 

Baths. — A cool sponge bath is always beneficial. 

Medication. — There is always marked improvement following free 
catharsis. Adults may take: 

I^ Podophyllin., gr. ^ to i; 

Calomel., gr. x; 

Pulv. aromat : gr. ij ; 

Sacchar., gr. x. 

M. S.: For one dose. 



INTESTINAL PUTREFACTION AND TOXEMIA 303 

On the following day five drops of dilute HCl in water may be given after 
each meal. When there is a tendency to constipation, a "lapactic" pill 
at night, or a teaspoonfiil of Carlsbad salt each morning in a cup of hot water 
will help. 

Abdominal massage is beneficial. Hot water or hot peppermint tea 
once a day is also helpful. 

Children may take: 

I^ Calomel., gr. j ; 

Sacchar., gr- x. 

M. S.: One such powder every hour until six are taken. 

Or we may order castor oil or citrate of magnesia or rhubarb and magne- 
sia, followed by two drops of dilute HCl in a teaspoonful of essence of pep- 
sine after eating. Infants should receive no breast or bottle milk for six 
to eight hours, and should have farinaceous water instead of sterilized 
milk in hot weather. 

Enteroclysis is helpful in intestinal indigestion in adults and children. 
Irrigation of the colon is a simple and valuable procedure. 

Intestinal antiseptics of the salol and naphthol group are in the market 
by the score. The best antiseptic for the bowel is its own action, and the 
writer has been more successful in the management of indigestion on the 
Imes laid down thanby tho administration of the modern coal tar derivatives. 
In gastrointestinal fermentation, and in indigestion secondary to cardiac, 
renal, and hepatic disease or acute infectious disease, we administer pepper- 
mint tea or dilute HCl after each meal, or 

I^ Tinct. iodini, gtt. x to xx; 

Syr. simpHcis, 5jv; 

Aq. menthse, 5jss. 

M. S. : A teaspoonful every hour or two, or several times a day. 

This is to be used in connection with saline irrigations of the colon. 



CHAPTER IX 
THE DIGESTIVE BY &T EM— Continued 

PROCTOLOGICAL MEMORANDA (RECTAL AILMENTS) 

Synopsis: Preliminary Remarks. — Catarrh of the Rectum (Simple, SyphiUtic, Atrophic 
Follicular). — Periproctitis and Abscess. — Impacted Faeces. — Foreign Bodies. — Condy- 
lomata (Syphilitic; non-Syphilitic). — Haemorrhoids (Internal, External). — Rectal 
Polyps. — Rigid Sphincter. — Pruritus Ani.— Prolapse of the Rectum. — Simple Fissure 
and Painful Ulcer. — Ulceration and Stricture of the Rectum. — Neuralgia of the Rec- 
tum. — Coccygodynia. — Remarks on the Upper Rectum and Sigmoid Flexure. 

PRELIMINARY REMARKS 

Examination. — An examination of the rectum is made by the finger 
and by means of a speculum in direct or reflected Ught. The upper rectum 
and sigmoid flexure may be inspected with the " Kelly tube." Constriction 
of the calibre of the intestine from organic disease or by pressure from with- 
out, and extreme tortuosity of the sigmoid flexure with adhesions, may 
prevent the use of instruments. A long flexible silver probe is useful for 
exploring fistulous tracts. The most comfortable and delicate position 
in which the patient may be examined is on the left side; the left arm 
brought behind the body, the right shoulder turned away from the examiner, 
the right thigh well flexed upon the abdomen. 

In interrogating the patient we inquire as to pain, protrusion of parts, 
discharge, gonorrhoea, bowel action, haemorrhage, syphilis, menstruation, 
and pregnancy. 

Before examining the patient the bowels must be moved, and in some 
instances local or general anaesthesia is necessary to a thorough examination. 
A knowledge of the state of the heart, kidneys, lungs, liver, central nervous 
system, and genital organs is essential to correctly interpret some of the 
conditions found in the rectum. 

In the management of rectal disease, as in the treatment of nasal disease, 
local treatment is of prime importance in conditions requiring operative 
interference, but in the various catarrhal conditions too much local treat- 
ment often prolongs the trouble, and therefore general hygienic manage- 
ment steps to the foreground. The interdependence of rectal and genito- 
urinary disturbances must not be overlooked. 

CATARRH OF THE RECTUM; PROCTITIS 

On careful local examination we can distinguish four forms: 
Simple acute catarrh, hypertrophic catarrh, atrophic catarrh, and follicular 
inflammation. 
304 



PROCTITIS AND IMPACTION OF FAECES 305 

Proctitis is a catarrhal inflammation of the mucosa from many causes. 
There is a sense of heat and weight in the perinanim, with a constant desire 
to defsecate. The anus is hot and tender, and there is a mucous discharge. 
This form of inflammation may terminate in speedy resolution or develop 
into periproctitis, abscess, fistula, or ulcer. 

General Treatment. — Remove the cause if possible. Order a dose of 
castor oil or a saline cathartic, a cold compress to the parts, or a suppository 
of opium and belladonna, aa, gr. ^. 

In periproctitis with ischiorectal abscess the treatment is' the same as 
in proctitis, and as soon as an abscess is evident, open it freely and pack 
the wound to allow it to heal from the bottom. A dressing of balsam of 
Peru or ichthyol ointment, 10 per cent, is advisable. 

Chronic atrophic catarrh is a common ailment. A dry, brittle condition 
at the margin of the anus is characteristic of this affection and gives rise 
to intractable pruritus. In addition, there is constipation with dry stools 
and some mucous discharge. 

Treatment. — Cleansing the intestinal tract with salt solution and inject- 
ing half an ouncu of a 5 or 10 per cent solution of argonin is appropriate 
treatment. Where there is distinct ulceration the insufflation of aristol or 
iodoform is excellent. Hydrochloric acid may be required to aid digestion. 

Hypertrophic catarrh is found in plethoric individuals. There is a persist- 
ent moisture at the anus, the stools are soft, liquid, or mucous, and there 
is marked flatulence with poor digestion. 

Treatment. — Phosphate of sodium before breakfast, a general tonic, 
hygienic measures, and hydrochloric acid to aid digestion. Locally, we 
inject into the rectum from one to six ounces of a 25 per cent solution of 
aqueous extract of krameria. 

Follicular inflammation, or catarrh, of the rectum shows a hyperaemic 
mucous membrane with small nodular, elevated swellings. Patients 
afflicted with this form of catarrh do not have a satisfactory stool, but go 
to the closet several times a day and pass small round masses coated with 
this mucus, and complain of flatulence. 

Treatment. — The treatment is local and constitutional, as in the other 
forms. 

IMPACTION OF pyECES 

The term impaction is used when the accumulation of fseces takes place 
in the pouch of the rectum. It may occur at any age and is due to inertia 
of the intestine or spasm of the sphincter, and it should be noted that a 
fluid discharge from the bowels (diarrhoea) is not incompatible with great 
retention of solid fseces. 

Diagnosis and Treatment. — The diagnosis is made by digital examination, 
and the impacted mass is removed by breaking it up with the fingers or by 
means of a spoon handle. After the patient is relieved, general hygienic 
and tonic management, including massage, are indicated. 

A rigid sphincter is often associated with fissure and is the cause of 
many cases of constipation in children and adults. It requires digital 
divulsion under narcosis by means of the thumb and index finger. This 
effort must be continued until the muscle has lost its power. 



306 THE DIGESTIVE SYSTEM 

Foreign bodies in the rectum are detected by digital examination and 
are removed under narcosis if necessary. 

Condylomata, warts, excrescences, vegetations, and mucous tubercles 
occur at the anus and vulva. There are two varieties: Condylomata lata 
and condylomata acuminata. Condylomata may be of syphilitic origin or 
may be due to irritation and filth. Those of syphilitic origin disappear 
after specific treatment and cauterization with nitrate of silver or chromic 
acid. The others may be snipped off with sharp scissors, and the bleeding 
spots should be cauterized. 

FISTULA IN ANO 

Definition. — A sinus left by an abscess in the neighborhood of the anus. 
A blind fistula has no communication with the intestine. A complete 
fistula communicates with the lumen of the intestine. The external orifice 
may be of the size of a pin or lie in the centre of a mass of granulations. 
The fistula secretes a thin purulent fluid. Now and then the orifice becomes 
obstructed, the discharge collects, a small abscess forms, and the skin becomes 
hot and tender. When this breaks, the symptoms subside. A certain pro- 
portion of anal fistulas are of tuberculous origin. In making a bacteriological 
diagnosis the Smegma bacillus should not be mistaken for the tubercle 
bacillus. 

Treatment. — The parts are made anaesthetic by means of cocaine or, 
according to Gant, by injections of sterile water under the skin. A grooved 
director is passed into the fistula and out through the anus and the tissues 
are divided until the director is free. Peroxide of hydrogen is now sprayed 
on the wound and the latter packed with iodoform gauze. The patient can 
go about on the following day, wearing a diaper or bandage. An incomplete 
fistula is made complete by forcing the grooved director through into the gut. 

H/EMORRHOIDS (PILES) 

Definition. — A varicose condition of the vessels around the anus, fre 
quently associated with eversion of the rectal mucous membrane. 
External haemorrhoids are of two kinds: 

a. A tag of skin somewhat inflamed. 

b. A thrombotic or blood clot haemorrhoid. 

The symptoms of both varieties are very much the same, heavy, weighty 
feeling and an aching pain. Some piles have an ulcerated surface. 

Treatment. — a. Palliative. A laxative medicine, heat or cold to the 
part, and subsequently the following ointment: 

I^ Calomel., 3ss. ; 

Ext. opii, "I __ 

Ext. belladonnjE, j ^^' ^^- ^' 

Vaselini albi, 5j. 

M. S.: Apply frequently. 

An ointment of tannin, opium, and belladonna, or of cocaine, gr. x, 
carbolic acid, gr. xx, and vaseUne, 5j, is also effective. 



FISTULA AND HEMORRHOIDS 307 

6. Operative. The skin haemorrhoid may be cut off at its base with 
a pair of scissors. The thrombotic pile should be slit open with a sharp 
knife and the blood clot released. The wound may be dressed with car- 
bolated vaseline. 

Internal Hcemorrhoids 

These are troublesome on account of haemorrhage, protrusion, and pain. 
They can readil}^ be distinguished from a polypus, which has a pedicle, and 
from prolapse of the rectum by its velvety appearance and uniformity of 
circumference. Cancer and ulceration of the rectum cannot be mistaken 
for hsemorrhoids by a careful examiner. Among the local causes of haemor- 
rhoids may be mentioned as of importance any condition which interferes 
with the return flow of blood from the rectum, tumors, the gravid uterus, 
constipation, and circulatory obstruction of hepatic, renal or cardiac origin. 

Treatment. — a. Palliative. The first indication is to prevent faecal 
accumulation and establish soft stools. With that object in view, we not 
only resort to certain medicines, but we must put the patient on appro- 
priate diet and under good hygienic surroundings. Absolute cleanliness of 
the anus and irrigation with tannic acid and alum are among the latter. 
Of medicines, rhubarb and its preparations, and pulv. liquirit. comp., are 
useful, but all drastic purgatives are to be avoided. When bleeding is 
copious, injections of fl. ext. of hamameL virg., a teaspoonful to a wine- 
glassful of water, used once daily, are sufficient. In the event of an 
" attack " of inflammation the patient is put to bed, the bowels are kept 
open, and heat or cold is applied. An ointment of opium and belladonna 
or cocaine is serviceable. After the " attack," daily cold water enemata 
may be continued for a long time. 

b. By Injection. A solution of carbolic acid may be injected into the 
protruding haemorrhoidal tissue once a week: 

I^ Acid, carbolic, pur., ) 

Glycerini, V equal parts. 

Aquae, ) 

M. S. : Inject five drops into the centre of the pile. 

This process takes several weeks to effect a cure. The instruments 
required to give the injections are: 

1. A hypodermic syringe of glass and a platinum needle two inches long. 
The needle can be readily sterilized by making it red hot in the flame of an 
alcohol lamp. 2. A rectal speculum with a section of its wall cut out and 
replaced by a sliding piece. This permits of the inspection and treat- 
ment of isolated portions of the bowel. 3. Aluminum or silver cotton car- 
riers with cotton for mopping and cleansing the parts. 

The patient is to have an enema a few hours before treatment. The 
small tumors are injected first, and the trifling pain from the needle can be 
overcome by applying a 5 per cent cocaine solution to the parts on a cotton 
swab. Two or three piles are injected at each sitting. Piles that do not 
protrude can be reached by means of the speculum. Two sittings a week 
can be safely carried out. 
21 ' 



308 THE DIGESTIVE SYSTEM 

c. Operative Treatment. Whitehead's Method. — Resection of the 
entire hsemorrhoidal area is an operation of some magnitude, and its 
success depends upon aseptic and primary healing in a region where 
asepsis is difficult to obtain. 

Allingham's operation. — Excision of each hsemorrhoidal tumor, with 
ligation of the vessel at its base, is free from risks and an excellent operation. 

The clamp and cautery operation can be rapidly performed and gives 
very satisfactory results. 

RECTAL POLYPI 

They are found in children and adults. They are pedunculated growths 
attached to the mucous membrane, and may be soft or fibrous, and are 
sometimes multiple. By thoroughly searching the bowel they can be felt 
and seen. They give rise to the following symptoms: Tenesmus, desire 
to go to stool, bleeding, and the passage of mucus. They may protrude 
from the anus on straining. 

Treatment. — They should be removed by means of a torsion forceps or 
by ligature. 

PRURITUS ANI 

Painful itching of the anus is a very distressing minor ailment, often 
very intractable, but eventually curable if the patient will persist in carrying 
out well directed treatment. The itching and irritation are worse at night, 
when the patient is in bed, and they interfere with sleep. Pruritus is 
possibly a pure neurosis, but usually there is some underlying local or 
constitutional cause, such as gout, diabetes, or hepatic disease, haemorrhoids, 
uterine disease, vaginal discharges, constipation, ascarides, or pediculi. 

The treatment must be directed to any underlying constitutional dys- 
crasia and the removal of local irritation. The parts should be thoroughly 
washed several times a day with soda water followed by a 2 per cent car- 
bolic acid solution. If an examination with a magnifying glass reveals 
fissures or breaks in the mucous membrane of the parts, cauterization 
with a 5 per cent nitrate of silver solution is indicated, three times a week. 

The following dusting powders and protecting ointments are useful: 

Stearate of zinc with acetanilide. 

Powdered starch. 

Powdered talcum. 

I^ Camphor ice, 5j; 

Acid, carbolic 5ss. ; 

Cocain., gr- x. 

I^ Vaselini, 5j; 

Ichthyol., 5j; 

Cocain., gr. x. 

I^ Vaselini, 5 j ; 

Menthol., 5ss. ; 

Bismuth subcarb., 5j- 

In intractable cases of pruritus a division of the nerves leading to the 
parts has been practised with apparent success. 



PROLAPSE, SIMPLE FISSURE AND ULCER OF THE RECTUM 309 



PROLAPSE OF THE RECTUM 

Prolapse or protrusion of the rectum is common in flabby, anaemic, 
and rhachitic children, but may occur at any age. 

Causes. — The causes are a relaxed state of the sphincter muscle, straining 
due to any local cause in the genitourinary and rectal regions, such as 
stricture, stone, a foreign body, a polypus, phimosis, worms, constipation, 
and piles. 

The protruding bowel may be recognized as such by its central aperture. 
In protruding intussusception a sulcus can be made out between the pro- 
truding bowel and the sphincter. In rare instances the protruding bowel 
may become strangulated and slough away. 

Treatment. — Reduction of the protrusion, strapping of the nates, regu- 
lation of the bowels, and rectal injections of cold alum water, 5ij to 1 qt., 
twice a day. General tonic and hygienic management will suffice for the 
majority of cases in flabby, anaemic children. 

Should such simple methods fail to cure, linear cauterizations with 
the galvanocautery or actual cautery in the long axis of the bowel are 
necessary and will cause the mucous membrane to adhere to the muscular 
coat by inflammation. In every case a careful examination will be necessary 
in order to exclude or detect and remove any source of local irritation. 

Prolapsus Ani in Children — Paraflin Injections. — For the relief of rectal 
prolapse in children Karewski (Centralblatt jur Chirurgie, July 12, 1902) 
has employed subcutaneous injections of paraffin having a melting point 
of 56° to 58° C. The patients, purged for two days, on the day previous 
to operation received large doses of bismuth to lock up the bowels. The 
field of operation was disinfected and the prolapse was reduced. A finger 
was then introduced into the rectum to act as a guide. Through one 
needle puncture the paraffin was injected in the form of a ring above the 
anus between the skin and mucous membrane. By suitable diet and the 
administration of bismuth an evacuation of the bowels was prevented for 
the following twenty-four hours. Eight children between two and eight 
years of age were treated by this method. One case was unsuccessful 
because of a faulty technique, but all the remainder were cured so far as 
could be judged from examinations made in from two to six months after 
the operation. In two cases the paraffin had to be injected a second time, 
and in a case of an idiotic, feeble child a third injection was made. In the 
remaining cases a single introduction of paraffin sufficed. Although in 
some of the cases the bowels moved during or shortly after the opera- 
tion, an infection never occurred, because the injection wound was kept 
protected. 

SIMPLE FISSURE AND ULCER OF THE RECTUM 

These very painful affections are found oftener in women than in men. 
Their location may be anterior or lateral, but it is usually dorsal, near the 
anus or high up in the rectum. They may be single or multiple. They 
are caused by straining and the passage of very hard, dry stools, and other 
causes. The patient complains of great pain on defaecation, and occasion- 
ally blood and matter are found in the stool. The agonizing pain induces 



310 THE DIGESTIVE SYSTEM 

the sufferer to postpone relieving the bowels as long as possible, and generally 
produces a high degree of nervous irritability. The site of the fissure or 
ulcer is often marked by a club-shaped papilla, more or less inflamed, 
protruding from the anus. On introducing the finger the ulcer is readily 
detected and is quite painful to the touch. 

Treatment. — A laxative should be taken at night, and the following 
ointment should be frequently applied: 

I^ Calomel, gr. xxx; 

Extr. opii. 



Extr. belladonnge, | ^^' ^''' ""' 

Vaselini alb., 5j- 

An occasional light touch with nitrate of silver is useful. 

Should the ulcer or fissure fail to heal by such management, the patient 
must be anaesthetized and the sphincter should be stretched thoroughly. 
A speculum is now introduced and the edges of the ulcer are cut away with 
a pair of sharp scissors and a knife is drawn over the ulcer, cutting through 
its base and if necessary into and through the external sphincter at right 
angles to its circular fibres. At the same time the aforementioned pro- 
truding club-shaped skin flap is also cut away. As a dressing, the above 
ointment will answer. This procedure will effect a cure. A fissure will 
heal after a thorough stretching of the sphincter. 

Ulceration located high up in the intestine requires irrigation through 
the colon tube every other day with ^ per cent nitrate of silver solution 
followed by normal saline solution. On alternate days an emulsion of 
bismuth, 5j, iodoform, gr. x, olive oil, 5iv, should be injected and retained. 
As a final resort, an artificial anus should be established and irrigation 
practised from above. 



ULCERATION AND STRICTURE OF THE RECTUM 

Congenital strictures have been mentioned in the chapter on Diseases 
of the New-Born. 

Acquired strictures may be due to pressure and constriction from without 
(pelvic inflammation), cancer, cicatrices from simple or dysenteric ulcera- 
tion or from injury, cicatrices from tuberculous ulcers, cicatrices from syphi- 
litic ulceration, cicatrices from soft chancre and gonorrhoea and unnatural 
practices. The syphilitic variety is often combined with condylomata. 
Fissures may form below the stricture, and haemorrhoids are a frequent 
concomitant. 

Symptoms, Diagnosis, and Prognosis. — Local pain, radiating pain, 
difficulty in having a motion, constipation alternating with diarrhoea, 
with the motions small and streaked with mucous discharge. In addition, 
there are general dyspeptic symptoms and belching of wind, and the patient 
becomes anaemic and worn out by constant suffering or from profuse haemor- 
rhage, and unless relieved dies of exhaustion or obstruction and peritonitis. 
There are often sympathetic vesical disturbance and loss of sexual power. 

The DIAGNOSIS is made by local examination with the finger and 
speculum, and when the trouble is high up, by means of Kelly tubes or an 



NEURALGIA OF THE RECTUM AND COCCYGODYNIA 311 

exploratory laparotomy. The great point to be decided is the distinction 
between cancer and non-malignant disease. Cancer of the rectum gen- 
erally runs its course in two or three years. A cancerous mass is hard to 
the touch, nodular, irregular, and without a pedicle, and involves ad- 
jacent parts. It may also present as a deep ulceration or a bleeding 
fungous mass, and frequently we find enlarged glands in the groin or in 
the hollow of the sacrum. In doubtful cases the microscope will aid in 
diagnosis. 

Even greater difficulties confront us when attempting to distinguish 
between the various forms of non-malignant strictures. Dysenteric ulcera- 
tion and contraction is known by its history. Tuberculous disease may be 
suspected from a coexisting lung trouble or from the patient's general 
condition. A reliable history of syphilis may justify the diagnosis of 
syphilitic stricture, and finally we must not forget that unnatural sexual 
intercourse, resulting in injury or infection, may be the cause of ulceration 
and contraction. 

Treatment. — Fibrous strictures can be overcome by dilatation, with 
and without linear incision (proctotomy). If syphilis or tuberculosis 
is the underlying cause, hygienic treatment and specific medication (with 
mercury, potassium iodide, etc.) must be employed at the same time. 
Electrolysis accomplishes little or nothing. Colotomy and extirpation of 
the rectum must be employed in otherwise intractable cases. Colotomy is 
indicated in old and incurable cases of non-malignant ulceration, stricture, 
and fistulse which are threatening life by exhaustion or obstruction. It may 
be indicated in obstruction exterior to the bowel, in cases of intestino- 
vesical fistula, and in "inoperable " cancer of the rectum, or when excision 
is for any reason contraindicated. The benefits of colotomy are manifest. 
The choice lies between the inguinal and the lumbar operation. Ability 
of the patient to care for the opening and secure cleanliness is in favor of 
the inguinal site. Opium or morphine must not be denied the sufferer 
from malignant strictures. 

NEURALGIA OF THE RECTUM 

A severe and sickening pain in the rectum, not aggravated by the action 
of the bowels, and for which there is no apparent local cause. It is not 
infrequent in older children and adults of a neurotic type, is more apt to 
come on in times of worry and excitement, and may come on during sleep 
and keep the sufferer awake for hours. 

Treatment. — Hygienic management, cold sponge baths, avoidance of 
constipation, and in severe cases a stretching of the sphincter muscle are 
indicated. If the patient is anaemic, iron or arsenic is indicated. If he 
is very neurotic, the bromides are to be given for a short time. Vibratory 
massage gives prompt relief in many cases. 

COCCYGODYNIA 

Definition. — Neuralgic pain in the sacrococcygeal joint. Not infrequent 
in neurotic women. 



312 THE DIGESTIVE SYSTEM 

Treatment. — The treatment is the same as for neuralgia in the rectum. 
A careful examination, to detect if possible a local source of irritation, 
should be made. In rare instances excision of the coccyx is necessary. 

THE UPPER RECTUM AND SIGMOID FLEXURE 

This region is accessible to some extent by means of the Kelly tubes. 
New growths, ulcers, and catarrhal conditions are found to exist here as 
in the lower rectum. 

The non-operative treatment consists in flushing the parts with saline 
or boric acid solutions and the local application of astringents and healing 
remedies. Hygienic measures and open bowels are the foundation of all 
treatment. Too much local treatment, particularly in catarrhal conditions, 
is meddlesome and harmful. 

The so called morning diarrhoea and mucous diarrhoea are generally due 
to some pathological condition of the rectum, sigmoid, or descending colon. 



CHAPTER X 

THE DIGESTIVE SYSTEM— Continued 

DISEASES OF THE LIVER, GALL BLADDER, BILE DUCTS, 
PANCREAS, PERITONvCUM, OMENTUM, AND ABDOMINAL 
LYMPH NODES 

Synopsis: Diseases of the Liver. — Preliminary Remarks. — Corset Liver. — Floating Liver 
— Displaced Liver. — Jaundice. — Acute Congestion of the Liver, Active and Passive. — 
Acute Yellow Atrophy of the Liver. — Chronic Hepatitis (Cirrhosis), Atrophic and 
Hypertrophic Forms. — Abscess of the Liver and Pylephlebitis. — New Growths of the 
Liver. — Echinococcus of the Liver (Hydatid Cysts). — Chronic Degenerative Processes 
of the Liver. — Syphilis of the Liver. — Atrophy of the Liver. — Fatty Degeneration of 
the Liver. — Fatty Infiltration of the Liver. — Amyloid Liver. — Inflammation of the 
Serous Coat of the Liver. — Aneurysm of the Hepatic Artery. 

The Gall Bladder and Bile Ducts. — Catarrh of the Bile Ducts. — Acute Inflammation 
of the Gall Bladder. — Gallstones. — Courvoisier's Law. — Dropsy and Empyema of 
the Gall Bladder. — Gallstones, Acute and Chronic Obstruction. — Indications for 
Operative Treatment. — Cancer of the Biliary Apparatus. 

Diseases of the Pancreas. — General Remarks. — Acute Hsemorrhagic Pancreatitis. — Acute 
Suppurative Pancreatitis. — Tumors of the Pancreas. — Pancreatic Calculus. 

Diseases of the Peritonaeum, Omentum, and Mesenteric Glands. — Acute Peritonitis. — 
Subphrenic Abscess. — Chronic Peritonitis. — Cancer of Peritonaeum and Omentum and 
Cysts. — Acute and Chronic Inflammation and Degeneration of Abdominal Lymph 
Nodes. 

DISEASES OF THE LIVER 
GENERAL REMARKS 

In order to fully understand the clinical pathology of the liver, the fol- 
lowing points should be borne in mind. The blood pressure in the portal 
capillary system is extremely low. Therefore minute disturbances may 
impede the flow of blood and produce passive congestion in the liver, and 
chemical and bacterial poisons from the intestines and in the blood and 
metastases of malignant growths readily affect the liver. Under normal 
conditions the liver dulness in the mamillary line extends from the lower 
border of the sixth rib to, or slightly beyond, the sternal border. 

Fluids in the right thorax, a massive indurated lung, exudates and tumors 
between the liver and diaphragm, and tumors of neighboring organs may 
simulate enlargement of the liver. Tympanites and ascites make the liver 
dulness appear small. Deductions based upon a small liver dulness should 
be carefully weighed. A large, tender, or very hard liver is not in a normal 
condition. A deformed Crhachitic) thorax may give to the liver an ab- 
normal position. 

313 



314 THE DIGESTIVE SYSTEM 

Corset liver and lobed liver are sometimes caused by tight- lacing and 
by wearing tight belts. 

A floating liver, or dislocated liver, is a rare condition which when found 
is probably an associated feature of pendulous belly and may be due to a 
congenital defect in the suspensory ligaments of the organ. A floating 
liver may give rise to various reflex symptoms and attacks of colic, which 
may be overcome to a large extent by the wearing of an abdominal support, 
as discussed in the chapter on Enteroptosis. 

JAUNDICE AS A SYMPTOM 

Jaundice may manifest itself in disease of the liver and in various other 
conditions in which the free flow of bile into the small intestine is interfered 
with. When the flow of bile is obstructed, and its production by the liver 
parenchyma continues, we have an overfilling of the gall bladder and a 
resorption of bile by the lymphatics into the general circulation, as shown 
by the icteric pigmentation of the tissues from light yellow to brown or 
green. The urine, the sweat, and inflammatory exudates show this colora- 
tion. The tears, saliva, and gastric juice do not as a rule appear yellow. 
The cholates of the bile also get into the circulation and act as systemic 
poisons. Jaundice is not dependent upon complete obstruction of the 
large bile duct, and any localized obstruction in the liver may be associated 
with jaundice. In gallstone colic with incomplete obstruction jaundice is 
often absent. 

The symptomatic jaundice in infectious septic conditions and in certain 
intoxications (phosphorus) is probably due to fatty degeneration of the 
liver cells, in which condition absorption may take place without obstruc- 
tion. Although we know that bilirubin may form from haemoglobin, 
owing to changes which take place in blood extravasation, it is pretty 
well established that a jaundice without the aid of the liver cells is not 
likely. 

Whenever bile fails to get into the intestine, nutrition is markedly 
interfered with, and when bile enters the circulation the cholates act as 
nerve poisons, blood pressure is diminished, the heart becomes slow and 
irregular in action, and coma may set in (cholaemia). A thick, tenacious 
bile is more readily absorbed than a thin bile. Cholsemic symptoms depend 
upon the concentration of the poison in the blood, so that we may observe 
intense jaundice without much constitutional disturbance. On the other 
hand, coma, convulsions, delirium, fever, etc., are observed in icterus 
gravis as well as in hepatic disease with little or no jaundice. 

Symptoms Associated with Jaundice. — In jaundice of long standing, 
we notice a tendency to haemorrhage from the mucous membranes (acquired 
hsemorrhagic diathesis), and we find the urine to contain albumin and hyaline 
casts in addition to bile. The skin, mucosa, and conjunctiva turn yellow, 
brown, or green. The skin becomes blotchy and itches. The stools are 
clay colored, pasty, and fcEtid. The heart's action is slow, notwithstanding 
a moderate rise of temperature, and the pulse may be intermittent. The 
patient is irritable, depressed, delirious, or comatose (typhoid state) and 
may have convulsive seizures. 



CATARRHAL JAUNDICE IN OLDER CHILDREN AND ADULTS 315 

Clinical Forms of Jaundice. — Jaundice of the new-born, mild and septic 
(see Paediatrics), mild catarrhal jaundice, at all ages, icterus gravis of hepatic 
origin (acute, chronic, infectious, and obstructive), injections jaundice, and 
toxic jaundice. 

Jaundice with Reference to Its Origin: 

Gastroduodenal catarrh, catarrh of the bile ducts, 

gallstones or worms in the bile duct, pressure on the duct 

Doixvui^xxv^ -!by tumors of any neighboring organ or fsecal accumulation 

or aneurysm, cicatricial stenosis of the bile duct, pressure 

[ of the gravid uterus. 

Hepatic ( Acute and chronic hepatitis, acute yellow atrophy of 

Jaundice. \ the liver. 

Microbial toxines (infectious disease), epidemic jaun- 
dice, jaundice following vaccination, influenza, typhoid 
fever, and other infections, also tonsillar infection, chemi- 
^ cal poisons, snake venom. 



Obstructive 



Toxemic 
Jaundice. 



Prognosis.— The prognosis of jaundice cases depends upon the under- 
lying cause. The mild, catarrhal form in children and adults terminates 
favorably in from one to six weeks. In the new-born, the mild form lasts 
from a few days to three weeks. Severe infectious jaundice in the new-born 
is usually fatal. 

The infectious, or toxic, jaundice in older children may last three to 
four months, particularly if occurring in subjects with jatty liver, and may 
end in recovery or death. In severe obstructive forms recovery depends 
upon our ability to remove the cause. In jaundice of long standing an 
exploratory laparotomy is indicated with the hope of finding and removing 
an obstruction (gallstones, stricture). 



CATARRHAL JAUNDICE IN OLDER CHILDREN AND ADULTS 

Treatment. — In mild, non-febrile cases the patients may be treated out 
of bed. Febrile and severe cases should rest in bed. 

Diet. — Milk, meat, eggs, cereals and other soft diet, stewed fruit, 
pineapple or orange juice, beef jelly, wine, tea, tropon in peppermint tea, 
water, Vichy, or Carlsbad water. Fat is to be avoided. Usually there is 
a loathing of food and the appetite must be tempted by offering palatable 
articles. 

Medication. — Five to ten grains of calomel should be given at once, 
followed by a saHne cathartic. Carlsbad salts or sodium phosphate may be 
given frequently to keep the bowels free. To aid digestion, five drops of 
dilute hydrochloric acid should be given in water, after eating. The so 
called cholagogues are probably useless. Large quantities of water by the 
mouth and per rectum are imperatively demanded. In protracted cases, in 
which syphilis or malaria is suspected as an underlying cause, quinine or 
Warburg's tincture may be given by the mouth or potassium iodide per 
rectum. In severe indigestion rectal alimentation may be employed, and 



316 THE DIGESTIVE SYSTEM 

the patient should remain in a covered hot bath, 105° F., for an hour daily, 
with the object of eUminating the systemic poison through the skin. Mild 
massage is beneficial. 

Itching may be controlled by powdering with starch or sponging with 
a warm soda solution. Furuncles and cold abscesses should be opened as 
soon as fluctuation is evident. 



HYPER^EMIA OR CONGESTION OF THE LIVER 

The liver, like any other organ, is subject to active and passive conges- 
tion. An active physiological hypersemia takes place during digestion. 
Thus, a heavy eater with little or no exercise may suffer from a liver which 
is actively or passively congested all the time. Active congestion is ob- 
served in malarial disease and dysentery and in diabetes. Passive conges- 
tion is the rule in pulmonary and cardiac disease and obstruction to the 
inferior cava. The nutmeg liver is often an evidence of such conditions at 
autopsies. 

Symptoms. — Hepatic congestion reveals itself by a dull, heavy feeling 
in the region of the liver and by a painful stitch. The patient prefers to 
lie on the right side. Dyspeptic symptoms are marked and slight jaundice 
may be observed, and the liver is enlarged and tender to the touch. A 
diagnosis of congestion of the liver means nothing unless we elicit the 
underlying cause at the same time, for it may be due to overfeeding and 
laziness, or it may be the beginning of hepatic cirrhosis, or it may be 
secondary to cardiac or pulmonary disease. 

Treatment. — The treatment will vary with the cause. The best way 
to influence a congested liver is by dieting (plain mixed diet, 2,000 calories), 
by exercising, and by purging with calomel, podophyllin, blue mass, or 
Carlsbad salts. 

In passive congestion from cardiac and pulmonary disease, and par- 
ticularly if dropsy is present, an infusion of digitalis should follow in the 
wake of a brisk purge, or venesection should be done. Carlsbad salts in 
hot water, in the morning, may be taken for a long time in hepatic congestive 
conditions. 



ACUTE YELLOW ATROPHY OF THE LIVER; MALIGNANT JAUNDICE 

This is a rare but fatal disease which may be defined as an acute infec- 
tion of the liver in which there is a rapid disintegration of the liver cells 
accompanied by great reduction in the size of the organ, with deep jaundice 
and grave nervous symptoms. The condition is similar to that produced by 
phosphorus poisoning. 

Symptoms. — The principal symptoms, extending over two to four weeks, 
are jaundice, vomiting, delirium, hsemorrhages, and rapid atrophy of the 
liver. Leucine, tyrosine, bile, and albumin are found in the urine. 

In the way of treatment nothing can be done beyond cleansing the 
alimentary tract and stimulating the patient. 



CIRRHOSIS OF THE LIVER 317 



CIRRHOSIS OF THE LIVER 



Definition. — A chronic hepatitis characterized by enlargement and 
subsequent atrophy, the liver being usually hard and small at the terminal 
stage of the disease. There is another class of cases called the hypertrophic, 
or biliary, form. Both are the result of an abnormal development of con- 
nective tissue, with contraction as a prominent feature in one, but not in 
the other. In the hypertrophic form the sufferer probably dies before the 
stage of contraction is reached. 

-Etiology. — Chronic hepatitis is due to microbial infection of the liver 
through the circulation and from the intestinal tract. Alcoholism and 
gastrointestinal fermentation are predisposing factors, also syphilis and 
malaria. The disease is most frequent in middle aged men and is also 
found in children; in the latter malaria, congenital syphilis, scarlet fever, 
and gastrointestinal fermentation are the predisposing factors. 

Symptoms and Diagnosis. — All forms of cirrhosis have practically the 
same symptoms, which are obstructive and toxic. The obstructive symp- 
toms are chronic gastric catarrh, occasionally haemorrhage from the ali- 
mentary canal, epigastric distention, enlargement of the spleen and of the 
epigastric veins, ascites and fluid in various cavities and oedema of the 
feet. Jaundice is often present. The spleen is generally enlarged, the urine 
is diminished and concentrated and may contain albumin, especially in 
the later stages, and the stools have a light color. The liver is large and 
tender in the hypertrophic stage and haemorrhoids are present. There is 
nothing characteristic as to the range of temperature. Dyspnoea is often an 
early symptom. In biliary cirrhosis (hypertrophic form), jaundice is almost 
as intense as in biliary obstruction, but the stools remain colored. The 
toxic symptoms are delirium, stupor, coma, and convulsions, as in any 
other form of toxaemia, and they occur in the terminal stage. 

The diagnosis of cirrhosis may be quite difficult to make, and only large 
clinical experience will enable us in some cases to distinguish between chronic 
passive congestion, cancer, amyloid liver, and tuberculous peritonitis with 
ascites. A condition of perihepatitis is sometimes observed at the autopsy 
in cases of hepatitis, the capsule of the liver being thickened. Pain is a 
prominent symptom in this class of cases. 

Prognosis. — The prognosis of advanced cases is unfavorable. 

Treatment. — As the disease in its early stages, when it might be in- 
fluenced by treatment, is frequently not recognized, the treatment of its 
pronounced manifestations is naturally symptomatic. However, it is no 
more than right that a patient suffering from chronic hepatitis should 
receive the benefit of such specific treatment as we possess, and in each 
and every case a course of antiluetic and antimalarial treatment is to be 
tried. Failing in our efforts in this direction, our symptomatic treatment 
will be conducted on the following lines: Enemata or laxatives, to secure 
daily bowel movement; ten drops of hydrochloric acid and ten drops of 
tinct. gentian, com., in water, after each meal, to aid digestion; daily moder- 
ate exercise and mild general massage and massage of the abdomen; a 
liberal diet (2,000 calories), avoiding cabbage, beans, pork, pastry, and fried 
fish; alcohol in moderation not to be forbidden for those who are accus- 



318 THE DIGESTIVE SYSTEM 

tomed to it; carbonated alkaline waters (Vichy), ginger ale, and pepper- 
mint tea are drinks to be recommended. 

Operative Treatment of Ascites and Cirrhosis of the Liver. — 
The writer was the first to employ permanent drainage for the relief and 
cure of ascites from cirrhosis and from other causes. The modus operandi 
of this procedure is described and illustrated in the article on Ascites. 

Talma's operation (the suture of the omentum to the peritonaeum) is 
not indicated in ascites due to causes other than cirrhosis of the liver. 
Permanent drainage and Talma's operation are indicated in cirrhosis of 
the liver in cases in which internal medication (particularly with iodide of. 
potassium) and paracentesis fail to afford relief, and in those cases in which 
there is no reasonable contraindication. 

ABSCESS OF THE LIVER AND SUPPURATIVE PYLEPHLEBITIS 

Hepatic abscess is always due to infection, but traumatism may be a 
direct incitive factor. The various pathological factors which give rise to 
abscess formation in the liver may be grouped as follows. Infection by 
means of foreign bodies (needle, fishbone, gallstones). Infection by means 
of parasites (echinococcus, round worms, amoeba, actinomycosis, etc.). 
Infection by means of pysemic embolism, from suppurative pylephlebitis, 
typhoid ulcer, ulcer in dysentery, tropical abscess, appendicular ulcer, 
pelvic suppuration, gangrene of the intestine, puerperal sepsis, gall bladder 
suppuration, etc. 

The infecting agent may reach the liver by way of the portal vein or 
hepatic artery. The abscess may be solitary or multiple. The so called 
"tropical liver abscess " occurs most frequently in the hot countries. 
Sporadic cases of tropical liver abscess are encountered as exotic manifesta- 
tions in the temperate zones. Hepatic abscess is at times the result of 
trauma; usually, however, it is the result of invasion of the hepatic tissue 
by various forms of parasites, protozoa, and pyogenic organisms. 

Symptoms. — The cardinal symptoms are irregular fever, chills, and septic 
phenomena, sweats, enlargement of the liver, hepatic and right shoulder 
pain, moderate jaundice, a sallow complexion, and gallstone disturbances. 
In doubtful cases aspiration of the liver is indicated. 

Differential Points. — In malarial fever the Plasmodium is found in 
the blood, and the administration of quinine brings improvement and 
cure. In typhoid fever we observe roseola and frequently a positive Widal 
reaction. Hepatic abscess may complicate typhoid fever. 

A right sided pyothorax may result from hepatic abscess breaking through 
the diaphragm into the pleural cavity. The aspirated pus in such cases 
is brownish in color and liver cells may be found with the aid of the micro- 
scope. Rapid cardiac failure with congestion of the liver and excruciating 
pain has been mistaken for hepatic abscess. 

The prognosis is grave. 

Treatment. — Surgical: When adhesions have formed between the 
liver and the abdominal wall and the abscess points, simple incision and 
drainage are indicated. When this is not the case, operative interference 
involves the opening of the abdominal cavity in order to have access to the 



NEW GROWTHS OF THE LIVER 



319 



liver. The single large abscesses offer the best chance for an operation. 
Pyemic abscesses and suppurative pylephlebitis are generally fatal. 
The NON-SURGICAL management is that of septicaemia. 



NEW GROWTHS OF THE LIVER 

The malignant new growths are primary and secondary cancer, including 
cancer of the bile passages; primary and secondary sarcoma. Clinically, 
carcinoma and sarcoma of the liver cannot be distinguished one from 
another. They are classified under one heading and will be spoken of as 




Fig. 114. — Cancer of the Livek (Dr. Halsey's case). 



"cancer." Cancer of the liver is usually secondary. It is a disease of 
late adult life and rarely occurs in children. It is less common in the 
tropics and in malarial districts than elsewhere. 

Symptoms. — Progressive enlargement of the liver, gastric disturbances, 
progressive loss of flesh and strength, pain or discomfort in the right hypo- 
chondrium, moderate jaundice in half the cases, ascites occasionally, 
palpable cancerous nodules in the late stages, a smooth liver surface in 
diffuse cancer, oedema of the feet usually, cachexia and anaemia marked, 
no characteristic fever curve, a duration of less than two years, and previous 
or concomitant carcinoma of other organs. 

Differential Points. — In hypertrophic cirrhosis the jaundice is deep, 
cachexia is less marked, and liver surface is smooth. In syphihtic amyloid 



320 THE DIGESTIVE SYSTEM 

liver with projecting gummata there is a syphiHtic history and there is less 
cachexia. A large, nodulated hydatid liver is recognized as such by puncture. 
Treatment. — Palliative treatment by hypnotics and sedatives is all 
that we can offer our patient at the present time. Whenever there is an 
element of doubt as to syphilis, an inunction course should be tried. Loeffler, 
of Germany, has recently recommended inoculation of malarial poison 
against carcinosis, and Beaton, of England, reports that carcinosis in women 
can be influenced by removing their ovaries. The influence of animal 
extracts and of x rays on carcinosis is still unknown. 

HYDATID CYSTS OF THE LIVER (ECHINOCOCCUS) 

The cyst is formed by the larvae of taenia, is unilocular or multilocular, 
and gives no marked symptoms in its incipient stage. A large cyst may 
present as a fluctuating swelling. If situated to the left of the suspensory 
ligament, pressure on the heart may result. The cysts may perforate any 
neighboring hollow organ. When suppuration in the cyst takes place, 
pyaemic symptoms supervene. The hydatid fremitus is a diagnostic sign 
in echinococcus cysts. In simple cysts the general health may be good. 
When hydatid cysts rupture or are punctured, urticaria often develops 
from absorption of irritating fluid. 

Differential Points. — In order to distinguish between hepatic abscess, 
carcinoma, and hydatid cyst, a puncture is necessary. Multilocular cysts 
and carcinoma cannot be distinguished without puncture. Dilatation of 
the gall bladder and hydronephrosis have been mistaken for echinococcus 
cysts. An examination of the puncture fluid will reveal the condition 
present. Hydatid cysts have been mistaken for right sided pleurisy. 
The puncture fluid of echinococcus shows albumin and free fluid containing 
hooklets. Sterile cysts contain no hooklets, and cysts which have been 
irritated may show albumin in the fluid. 

Treatment. — Medication and injections into the cyst are useless. When 
simple aspiration fails to cure, incision is indicated. 

CHRONIC DEGENERATIVE PROCESSES IN THE LIVER 

The conditions to be briefly described under this heading have more 
of a pathological than clinical interest, inasmuch as they represent patho- 
logical incidents in the course of various systemic diseases. 

Atrophy of the Liver may result from all forms of cachexia or marasmus. 
The liver is small. 

Fatty Degeneration is observed in poisoning by phosphorus and in acute 
infections. The liver is small. 

Fatty Infiltration is often associated with general obesity and severe 
anaemia. It is quite common in children in gastroenteric and other acute 
infections. The liver is enlarged. 

Amyloid Liver is observed in the cachexia of chronic suppuration, 
chronic malarial disease, chronic gout, syphilis, leucaemia, and pseudo- 
leucaemia. The liver is enlarged. 

In all these conditions a consideration of the underlying cause leads 
to the diagnosis, gives the prognosis, and indicates the treatment. 



GALLSTONES 321 

Syphilis of the Liver. — In congenital syphilis of the liver we observe dif- 
fuse infiltration, gummata, and chronic induration (syphilis hereditaria tar- 
da). In acquired syphihs, the diffuse infiltration and gummata are present. 

The TREATMENT is antisyphilitic and sustaining. 

DISEASES OF THE GALL BLADDER AND BILE DUCTS 

ACUTE CATARRH OF THE BILE DUCTS (NOT CAUSED BY GALLSTONES) 

This inflammation is due to an extension of gastroduodenitis from 
indigestion, infection, or passive congestion. The cardinal symptoms are 
jaundice and indigestion. If the jaundice persists longer than three months, 
an exploratory laparotomy may be indicated in order to locate and remove 
if possible a serious obstruction. Otherwise, the prognosis is favorable 
and the treatment is that of catarrhal jaundice. 

Acute Inflammation of the Gall Bladder is an infection of this organ, 
with or without the presence of gallstones. The symptoms are those of 
hepatic colic, paroxysmal pain, oftentimes jaundice, local tenderness, fever, 
nausea, vomiting, abdominal distention and rigidity, and general prostration. 

The differential points in diagnosis will be discussed under Gallstones. 
In doubtful cases a probatory puncture into a palpable swelling or distended 
gall bladder is indicated, or an exploratory laparotomy is demanded. 

Treatment. — Mild manifestations of gall bladder inflammation may 
subside under the application of a hot water bag to the parts, a brisk cathar- 
tic, and subsequently morphine subcutaneously to quiet pain. When the 
symptoms become urgent and suppuration and sepsis are suspected or are 
evident, the treatment becomes surgical. An operation is required in 
nearly all cases of empyema or dropsy of the gall bladder and in persistent 
recurring colic from inflammatory adhesions. Aspiration through the abdom- 
inal walls will not affect a cure and is hazardous. The choice of oper- 
ation after opening the seat of disease lies between cholecystotomy, cho- 
lecystectorny, and cholecystenterostomy, and must be left to the judgment 
of one who is experienced in this class of surgery. 

GALLSTONES 

Concrements from bile are deposited generally in the gall bladder and 
occasionally in other parts of the bile tract in and outside of the liver. 
They occur in all sizes and numbers. They are composed of cholesterin, 
lime salts, bilirubin, etc. Normal bile is sterile and is kept sterile by a 
centrifugal flow of bile. Microbial invasion may take place through the 
circulation during typhoid fever and grippe or by way of the intestines. 
This invasion of microbes is favored by a stagnation of bile, viz.: an atro- 
phic condition of the gall bladder from old age, gravidity, and tight lacing. 

Microbial invasion produces catarrhal conditions of the lining of the 
gall ducts. Epithelia with undissolved cholesterin are detached and form 
centres of crystallization or deposit, and the nucleus or starting point of 
gallstone formation is thus afforded. Concrements in the gall ducts do 
not invariably irritate, but they frequently give rise to pain, inflammation, 
adhesions, abscess, and perforation. 



322 THE DIGESTIVE SYSTEM 

The microbic theory of gallstones is now an established fact. It is 
probable that the microorganisms favor the precipitation of certain elements 
of the bile, btit the microbes cause a catarrh, which may not be recognized 
clinically. The degeneration of the epithelial cells produces the cholesterin 
and lime. 

Lithiasis is a result of the infection of the whole biliary tract or of the 
gall bladder alone. 

Calculi may be divided into two classes — those produced by the colon 
bacillus and those by the typhoid bacillus. The colon bacillus is the most 
frequent cause. The presence of aseptic foreign bodies in the gall bladder 
does not produce inflammation and does not seem to affect its function, if 
the cystic duct remains patent. There is no precipitation of cholesterin 
when the bile remains clear and free from microbes. 

Bile, stagnant in an aseptic gall bladder, has no tendency to precipitate. 
It is probable that the microorganisms find their way into the gall bladder 
through the duodenal opening of the common bile duct. The possibility 
of entrance through the blood vessels must be allowed, but has not been 
proved. 

If the ductus cysticus becomes occluded, we observe dropsy of the gall 
bladder or eventually empyema with ulceration and perforation into the 
liver, intestine, stomach, or peritonaeum. Malignant growths often find a 
foothold on perforating ulcers. Cholelithiasis and carcinosis are companions. 

Gallstone colic is associated with great pain, vomiting, fever, and occasion- 
ally jaundice. Spasmodic contraction of the gall ducts produces pain just 
as we observe it in the ureter and intestine. Children are not subject to 
gallstones and women are more subject than men. 

Symptoms, Diagnosis, and Differential Points. — As long as a calculus 
remains free in the gall bladder no urgent symptoms are produced. When 
impaction occurs in the cystic or common bile duct, urgent symptoms are 
manifest. Colic is the main symptom, accompanied by nausea, vomiting, 
sweating, a rapid pulse, depression, and frequently, but by no means in- 
variably, jaundice, for an impacted gallstone need not entirely obstruct 
the flow of bile. 

As a rule there is fever of an indefinite intermittent type during an attack 
of gallstone colic. The pain of biliary colic is acute and cutting and is 
localized in the region of the gall bladder, whence it spreads over the ab- 
domen, thorax, and back and frequently into the right shoulder. The 
liver and gall bladder are tender, particularly if the hand is pushed beneath 
the free border of the thorax. 

The duration of an attack varies; it may be over in an hour or two, and 
with remissions and exacerbations may last a week or two until the stone is 
expelled. Impaction in the cystic duct may develop without jaundice and 
may distend the gall bladder into a palpable tumor which, unlike a wander- 
ing kidney, moves with respiration. Occasionally gallstone crepitus may be 
perceived. As a result of cystic duct impaction, we observe dropsy of the 
gall bladder or inflammation and empyema of the gall bladder. In case of 
perforation by the stone, a localized abscess or general peritonitis may ensue. 

Courvoisier's Law. — Of distinct value in practical diagnosis is the ob- 
servation of Courvoisier, made in 1890, in regard to the enlargement of the 



GALLSTONES 323 

gall bladder from obstruction of the common duct. The law is this: When 
the common bile duct is obstructed by a stone, the gall bladder does not 
enlarge, whereas when the obstruction occurs from other causes, enlarge- 
ment is generally present. In explanation of this anomaly it is suggested 
that if there is a stone in the common duct, there are probably several 
others in the gall bladder, the presence of which excites inflammatory action, 
this in turn being followed by a contraction of the tissue walls of the viscus. 

Impaction in the common duct gives rise to jaundice and symptoms 
of catarrhal and suppurative cholangeitis. There is an intermittent presence 
of bile in the stools, occasionally fever, and some enlargement of the liver. 
The gall bladder may be distended or atrophic. 

Differential Points. — A colic as described, plus jaundice and a history 
of previous attacks, makes the diagnosis of gallstone almost positive. 
After an attack the stools should be passed through a rotating flour sieve 
and search made for the stone. 

In locali '.ed paroxysmal pain without jaundice we must discriminate 
from the following conditions: In inflammation and adhesions of the gall 
bladder without stone the absence of stone can be made out only at the time 
of operation (Morris' spider cases). In renal colic the pain radiates from the 
lumbar region into the lower abdomen, groin, thigh, and testicle. The 
lumbar region is often tender on pressure and the urine may show blood, 
haemoglobin, and calculi. In gastralgia the pain is in the middle epigastrium 
and radiates more to the left; fever and jaundice are absent, and no gall- 
stones are found in the stools. In appendicitis the pain is localized over the 
appendix, the appendix is tender on palpation, jaundice and tenderness of 
the liver and gall bladder are not observed, and a gallstone is not found in 
the stools after the attack. In enteralgia or intestinal colic the pain is in 
mid-abdomen and is relieved by pressure and the passage of flatus. 
Jaundice is absent and stones are not found in the stools. 

Complications and Sequelae. — Gallstones may be expelled at irregular 
intervals, with symptoms of colic not urgent enough to demand operative 
interference, and a cessation of the symptoms may result. Stones of all 
sizes may pass or ulcerate into the bowels and be discharged with the stools. 
Very large stones may cause intestinal obstruction. Stones may ulcerate 
and perforate into any neighboring organ or locality and produce abscess, 
fistula, or peritonitis. 

Treatment. — The prompt way of relieving the intense pain of gallstone 
colic is to give a hypodermic injection of morphine (gr. j to i), to be repeated 
if necessary. The patient may also place a hot water bag over the seat of 
pain and drink hot peppermint tea. In lieu of hypodermic medication the 
following prescription for internal use is offered: 

I^ Morphin. sulph., gr- j J 

Chloroformi, 1 __ ^. 

Pulv. acaciffi, j ^^' ^^' 

Aquae, ad., 5iij- 

M.: ft. emuls. et adde^ 

Syr. sacch., '. 3jv. 

S. : A teaspoonful every half hour until the patient is relieved. 
22 



324 THE DIGESTIVE SYSTEM 

After the attack the bowels must be kept open by Carlsbad salts or 
enemata. 

The indications for operative treatment vary with each individual case. 
The age of the sufferer is to be considered. Patients with a senile heart 
are not promising subjects for operative interference. An exploratory 
laparotoni}^ in doubtful cases is better than theoretical speculation. If 
after opening the abdomen the conditions are found to be favorable for 
radical operative measures, they should be employed. An operation per- 
formed while the stones still remain in the gall bladder or cystic duct gives 
the best results. 

MORTALITY AFTER OPERATIONS FOR GALLSTONES* 

1. 237 Conservative operations (cystostomies, cystendyses, cysticotomies), 

with 5 deaths 2.1 per cent 

2. 161 Cystectomies, with 5 deaths 3.1 " 

3. 137 Choledochotomies, with hepaticus drainage, with 9 deaths 6.5 " 

4. 114 Simultaneous operations on the stomach, intestines, pancreas, liver, 

kidney, etc., with 24 deaths 21 . " 

5. 71 Simultaneous operations in "inoperable" carcinoma of the gall blad- 

der, choledochus, liver, diffused suppurative cholangeitis, diffused 
suppurative peritonitis, sepsis, with 69 deaths 97 " 

Total: 720 laparotomies, with 112 deaths 15.5 per cent 

Deducting (4) 114 operations, and 
(5) 71 operations. 
*535 Uncomplicated LAPAROTOMIES FOR GALLSTONES, WITH 19 deaths, 3.5 per cent. 
— Professor Hans Kehr, of Halberstadt, Germany, 1902. 

CANCER OF THE BILIARY APPARATUS 

Cholelithiasis and carcinosis are companions. Cancer of the gall bladder, 
if primary, is almost invariably associated with gallstones. Frequently it 
is secondary to cancer of the liver and neighboring organs. 

Symptoms. — Pain, tenderness, chronic jaundice, fever, cachexia, haemat- 
emesis, etc. Sometimes a tumor can be felt. A positive diagnosis is made 
by exploratory laparotomy. The disease is fatal. 

DISEASES OF THE PANCREAS 

GENERAL REMARKS 

The pancreas is situated in the curve of the duodenum, across the first 
and second lumbar vertebrae, and is extraperitoneal. It occupies the region 
from six to twelve centimetres above the umbilicus. The gland is of the 
compound racemose type and secretes a very active digestive fluid. This 
fluid consists of four well known ferments, acting upon separate classes 
of food: Trypsin, acting upon the proteids, changing them into peptones; 
amylopsin, acting upon the starches, converting them into maltose and then 
into glucose; rennet, coagulating the milk when in the presence of an 
acid; and steapsin, emulsifying the fats and changing them into soap. 
The amount of pancreatic secretion in a case of Cushing's was found to be as 
high as 660 grammes daily, and all was not then obtained. This is a much 



ACUTE SUPPURATIVE PANCREATITIS 325 

larger amount than was formerly believed to be secreted by the gland 
The curve of the amount secreted was greatest during the day and decreased 
as the night advanced and the upper intestines were emptied. This action 
corresponds with the belief that food stimulates the flow of the pancreatic 
secretion. The nerve supply is probably through the pancreatic, but the 
mode of action is not definitely known. The sympathetic system may also 
be found to have some influence, because the amount of secretion varying 
with the amount of food to be acted upon in the intestines indicates a close 
nervous relation between these organs. 

Hcemorrhage into the pancreas is one mode of sudden death. The patients 
are previously well and are taken with sudden severe epigastric tenderness 
and pain, increasing in severity and colicky in character. Nausea and 
vomiting usually follow, and the patient becomes anxious and restless. 
The pulse is weak and rapid and later becomes imperceptible. The tem- 
perature is that of shock, normal or subnormal. Tympanites is sometimes 
marked. The bowels are usually constipated. The diagnosis is certainly 
most difficult, and if it is made, surgical relief would be indicated. 

ACUTE HyEMORRHAGIC PANCREATITIS 

Acute inflammation accompanied with small haemorrhages into the 
interlobular tissues usually occurs in males with an alcoholic history. The 
onset is sudden, with violent colicky pain in the upper abdomen, nausea, 
vomiting, and collapse. Constipation is the rule. The abdomen becomes 
swollen and tense. The temperature is at first low, then high. Delirium 
usually accompanies the attack. The condition must be distinguished from 
acute perforative peritonitis and intestinal obstruction. 

Treatment. — The treatment would be symptomatic. Prescribe rest in 
bed, unload the bowels, apply cold over the abdomen, and order a fluid diet. 

ACUTE SUPPURATIVE PANCREATITIS 

The inflammation may occur as a single focus or as diffuse suppurative 
foci. The symptoms are not clear, but are usually of some duration. The 
attack may come on suddenly with severe pain, vomiting, fever, and 
delirium. A deep seated mass may be felt in the median line above the 
umbilicus. This may be accompanied by an attack of jaundice and fatty 
diarrhoea, with or without sugar being present in the urine. When glyco- 
suria has been present, destruction of the islands of Langerhans has been 
found at the necropsy. 

Treatment. — The treatment would be surgical. 

Gangrenous inflammation of the pancreas may follow any of the follow- 
ing conditions: Acute hcemorrhage, acute inflammation, simple or suppura- 
tive, injury to the organ, and perforative ulcer of the stomach. 

The whole or a portion of the organ may be involved, and the disease 
may terminate in death or recovery in two or three weeks. 

Diagnosis. — The diagnosis of the condition would depend upon the 
history and symptoms, which are very much like those of suppurative 
pancreatitis. 

Treatment. — The treatment of such a condition would be surgical. 



326 THE DIGESTIVE SYSTEM 

Chronic inflammation of the pancreas is usually associated with a chronic 
catarrhal process of the stomach, duodenum, or bile ducts, and is an ex- 
tension through the ducts. A few cases may follow syphilis, alcohoUsm, 
and general arteriosclerosis. The inflammation may be hsematogenic, 
due to toxines in the blood, and hence follow typhoid fever, influenza, or 
some other toxaemia. If infection is the cause, prolonged drainage of the 
gall bladder has been recommended. 

Atrophy of the organ is usually associated with diabetes, or chronic 
interstitial inflammation of the head of the gland, or a blocking off of the 
ducts. 

TUMORS OF THE PANCREAS 

Tumors of the pancreas are usually carcinomatous, rarely sarcoma, 
adenoma, lymphoma, tuberculous, or syphilitic. The head of the organ 
is usually the seat of the disease, though the body or tail may be involved. 
The growth usually occurs in people of middle life. 

Diagnosis. — The diagnosis of the condition is not often possible, as 
there are no regular symptoms and the growth may be present without 
symptoms. The most common association of symptoms is the following: 
Rapid cachexia and pain, which may be continuous or paroxysmal and 
situated in the epigastrium. Nausea and vomiting may coexist. Jaundice, 
from occlusion of the common duct with distention of the gall bladder, 
may be severe and increasing. The presence of a tumor is very variable 
and may or may not be made out. Pulsation, with or without a bruit, 
may be discovered. Thrombosis of the portal vein and its sequelae may 
complicate the condition. Symptoms from loss of function are not common, 
hence fatty diarrhoea is not frequent. The stools are clay colored and 
greasy from the absence of bile. Diabetes is rare. Dilation of the stomach 
and stenosis of the pylorus from pressure of the growth may exist. If 
the diagnosis is made early, the only hope lies in complete extirpation of 
the growth, including all involved glands and tissue; otherwise the outlook 
is hopeless. 

CYSTS OF THE PANCREAS 

Cysts are due to inflammation, or retention from occlusion. 

The history of one variety involves blows or oft repeated pressure over 
the pancreas as the existing cause. The symptoms are pain and vomiting 
and later the pressure of a tumor. Following inflammation there are 
severe symptoms coming on suddenly with pain and obstruction of the 
ducts, causing the later development of the tumor. Without preceding 
trauma or inflammation, there may be cystic formation from retention by 
plugging of the main ducts, or from proliferation of glandular tissue and 
occlusion of a duct, or many small occlusion cysts from chronic interstitial 
changes in the alveoli. 

It seems proper to mention here the pseudopancreatic cysts due to 
haemorrhage into the lesser sac of the peritonaeum. Such a condition 
may follow trauma or inflammation, and resembles in position and symp- 
toms true cysts of the pancreas. The anatomical situation of these cysts 



TUMORS AND CYSTS OF THE PANCREAS 



327 



is in one of three places: In the lesser sac between the stomach and colon; 
rarely if ever above the stomach ; and between the peritoneal layers of the 
transverse mesocolon. Thus the physical signs of the tumor will appear in 
one of these three positions, in the epigastrium, with only slight lateral 
displacement from the median line. 

Irrespective of the anatomical position, the symptoms in general of 
all of these cysts are similar, though every one is not necessarily present in 
each instance — attacks of colicky pain, nausea, and vomiting, with progres- 
sive enlargement of the abdomen. Fatty diarrhoea is rare, as is salivation. 
Glycosuria, however, is frequent. Jaundice may occur from pressure 
obstruction of a duct. Dyspnoea may be present, due to the size of the 
cyst. In some cases there may be loss of flesh. Sudden temporary dis- 
appearance of the cyst may occur, due to the discharge of its contents into 
the intestinal canal. 

Physical signs of these cysts depend, as stated above, upon the anatomical 
position. Hence the tumor usually appears as a hemispherical bulging 
in the median line of the upper abdomen, rarely as a lateral tumor. It is 
immobile and unaffected by deep inspiration. As a rule, the stomach is 
above and the colon crosses below. The aspirated fluid is reddish or dark 
brown in color, containing blood, blood coloring matter, and cell detritus, 
with fat granules. The consistence is mucoid and the reaction alkaline. 
The specific gravity varies from 1,010 to 1,020. It may contain one or 
all of the pancreatic ferments, but the digestion of fibrin or albumin is the 
only reaction regarded as a positive sign. The absence of all ferments is 
not regarded as negative proof. 

The following conditions must be distinguished from pancreatic cysts: 



Malignant Tumors 

Pain continuous. 
Loss of flesh and strength. 
Progressive local and general in- 
fection causes a multilocular cyst. 
Hardness. 
Surface nodular. 
Duration of months. 



Aneurysm of the Abdominal Aorta 
Expansile pulsation. 

Bruit. 

Size diminished by steady pressure. 



Peritonitis 



Fever. 

Pain. 

Tenderness. 



Pancreatic Cysts 

Not usually present until large. 

Rarely. 

Usually unilocular. 

Cystic feel. 

Smoothness. 

Weeks. 



Pancreatic Cysts 

Pulsation ceases in the knee-chest 
position. 

Not affected by pressure. 

Pancreatic Cyst 
Symptoms less intense. 



328 



THE DIGESTIVE SYSTEM 



Ascites 
Causes for ascites. 

Aspirated fluid gives character. 

Cystic Ovary 
Examination and history. 

Hydronephrosis or Pyonephrosis 

History points to the kidney or 
ureter. 

Examination of the urine. 

Dulness below the kidney posteri- 
orly. 

Echinococcus Cyst 

Peculiar pseudocrepitus. 
Multilocular. 

Presence of booklets in the aspirated 
fluid. 

Retroperitoneal Glandular 
Enlargement 

Preceding history and other symp- 
toms. 

Cyst of the Suprarenal Gland 



Pancreatic Cysts 

History and onset of symptoms 
differ. 



Pancreatic Cyst 
Digestive disturbances. 

Pancreatic Cyst 



Tympany in the lumbar region be- 
low the kidney. 



Pancreatic Cyst 



Not present. 
Unilocular. 



Pancreatic Cysts 



Pancreatic Cyst 



Not possible to distinguish. 



PANCREATIC CALCULUS 

This condition is rare and its symptoms are seldom defined sufficiently 
to make a diagnosis. The concretions are usually multiple and resemble 
fragments of white coral. In substance they are carbonate of calcium. 

The symptoms, if present, are due for the most part to the effects of 
the stone on the gland ; hence we observe a chronic interstitial inflammation 
of glandular substance with dilatation of the duct. This condition may 
go on to the formation of cysts. There may be acute suppurative inflamma- 
tion of the gland. The irritation of the deposit may be followed by car- 
cinoma. Under the foregoing conditions, the symptoms leading to sup- 
puration from stone would be severe colic, fatty diarrhoea, and glycosuria 
without other explanation. 



ACUTE PERITONITIS 329 



SURGERY OF THE PANCREAS 

The advance of pancreatic surgery has been greatly hindered by the 
difficulties of diagnosis and by the great danger attendant upon operation 
on this gland, particularly from leakage of the pancreatic secretion, which 
seriously irritates the peritonaeum. 

The results of operations in chronic pancreatitis are encouraging. 



DISEASES OF THE PERITON>EUM, OMENTUM, AND 
MESENTERIC GLANDS 

The peritonceum is the inner lining of the abdomen and pelvis, and 
is reduplicated at various points so as to partially or completely envelop 
the various intrapelvic and intraabdominal organs. 

Clinical Varieties of Peritoneal Inflammation.— The clinical varieties are 
ascites (hydro peritonaeum), acute peritonitis (diffuse and localized), sub- 
phrenic abscess, chronic peritonitis, diffuse and localized (simple, tubercu- 
lous, syphilitic, gonorrhoeal, and malignant). 

Peritonitis is an inflammation of the peritonaeum, and on opening the 
abdomen in such cases we find clear or cloudy or haemorrhagic effusion, 
creamy or foul pus, and plastic lymph deposits, and in case perforation of 
the intestine has taken place we may find faecal matter in the abdominal 
cavity. 

Clinically, we recognize acute, subacute, and chronic peritonitis with 
periods of quiescence and periods of exacerbation of inflammatory symp- 
toms. Peritonitis may result from injury with infection (including imperfect 
surgical technique), from an extension of an inflammatory process of a 
neighboring organ with or without perforation, and from metastasis through 
the blood and lymph channels in all infectious and septic processes. We 
have evidence of prenatal peritonitis in the shape of intraabdominal ad- 
hesions and bands. In the new-born septic peritonitis may develop from 
the navel. In childhood and adult life severe enteritis, appendicitis, 
typhoid ulcer, tuberculosis, trauma, and infection are the exciting factors 
in peritonitis. 

When the causative factor is unknown, we speak of idiopathic peritonitis. 
In the present state of our knowledge this term is too indefinite and un- 
satisfactory and had better be dropped. 

ACUTE PERITONITIS 

A primary, or idiopathic, peritonitis is supposed to occur as a terminal 
event in chronic nephritis, arteriosclerosis, and gout. Acute primary 
infection is theoretically as likely as the infection of any other serous 
membrane through the blood, but practically almost all of our cases of 
peritonitis are secondary, viz.: By extension of a neighboring inflammation, 
by perforation of gastrointestinal ulcers (simple, tuberculous, cancerous, 
stercoraceous, or typhoid, or due to intestinal stone), by rupture of any 
neighboring pus sac, as in appendicitis, pyosalpinx, and by pyaemic infec- 
tion (puerperal infection). 



330 THE DIGESTIVE SYSTEM 

Symptoms. — When the patient is already ill and a slow spreading gen- 
eral peritonitis develops as a complication, the onset may be sudden or 
slow and insidious. The pain becomes general, the abdomen tender, dis- 
tended, and tympanitic, and the patient's knees are drawn up to minimize 
abdominal tension. The respiration is costal and rapid (30 to 40) , vomiting 
may be persistent (green vomit), and the pulse is rapid and small (110 to 
150). The temperature may be normal or subnormal or high. The urine 
contains much indican, and there is a tendency to collapse. The face is 
anxious, the skin is cold, and the mind may be quite clear. On examination 
the abdomen is found motionless or rigid, and on auscultation we may hear 
peristaltic restlessness, or in case of intestinal paresis we notice an absence 
of intestinal gurgling. The hepatic dulness soon disappears and an effusion 
may become manifest. 

Differential Points. — In severe enterocolitis simulating peritonitis there 
is profuse diarrhoea with only moderate meteorism and abdominal rigidity. 
In intestinal obstruction there is no decided rise of temperature, no passage 
of flatus or faeces, and faecal v^omiting generally occurs. The high tempera- 
ture and rigid abdomen are marked only in the later stages. In rupture 
of an ectopic gestation sac there is a characteristic previous history — no 
fever, breast signs, menstrual irregularities, with a small pulse and collapse 
after the rupture. 

Acute localized peritonitis occurs principally in three varieties: Pelvic 
peritonitis, peritonitis around the appendix, and subphrenic peritonitis 
or abscess. Pelvic peritonitis is discussed under Gynaecological Memoranda. 
Appendicular abscess is discussed under Appendicitis. 

Treatment of Acute Peritonitis. — The management of acute general 
peritonitis depends upon circumstances and the underlying cause. Hot 
water or ice bags may be applied locally over the abdomen and full doses 
of opium may be given by the mouth, or morphine (gr. J) and atropine 
(gr. xio) subcutaneously. The diet should be diluted milk, slimy gruel, 
white of egg in water, tea, peppermint tea, champagne, water ice, ice cream, 
tropon, 5j to a cup of tea, and ice to suck. 

If vomiting persists, rectal alimentation must be relied on, and one 
drop of tincture of iodine should be given in a teaspoonful of sweetened 
peppermint tea every hour. The lower bowel may be flushed with a pint 
of warm saline solution once or twice a day. When the infection is wide- 
spread, it may become necessary to open the abdomen and flush with 
hot salt water. There are no strict rules to guide us as regards indications 
for operative interference in diffuse peritonitis; each case must be judged 
upon its merits. A localized peritonitis and abscess formation require 
prompt incision and drainage. As a heart stimulant, camphor in oil, sub- 
cutaneously, or benzoate of sodium and caffeine, subcutaneously, is in- 
dicated. 

The PROGNOSIS in diffuse peritonitis is grave. The pulse is the best 
index to the gravity of the infection, A rapid pulse and incessant vomiting 
and high septic temperatures, all combined, give a fatal outlook. 



SUBPHRENIC AND CHRONIC PERITONITIS 331 



SUBPHRENIC PERITONITIS (ABSCESS) 

A subphrenic abscess is an accumulation of pus between the liver and 
the diaphragm or between the stomach, the spleen, and the diaphragm. 

Causation. — Perforation of a gastric or duodenal ulcer. Upward ex- 
tension of any intraperitoneal inflammation or abscess, or any form of 
suppuration taking its origin in the liver, gall bladder, stomach, spleen, 
circumrenal tissue, pancreas, appendix, intestine, hydatid cysts, or trauma. 
Downward extension of an empyema through the diaphragm. In some 
instances we have to deal with a subphrenic abscess containing air — pyo- 
pneumothorax subphrenic us. 

Subphrenic abscess occurs in adults and in children. The writer has 
seen two instances in children, one taking its origin from the perforated 
appendix in a girl of five and the other from a perforation of the ascending 
colon, left side abscess, in a girl of ten. Both patients recovered after an 
operation. 

Symptoms of Subphrenic Abscess. — The symptoms may come on ab- 
ruptly or insidiously. In addition to the general symptoms of sepsis, 
such as fever, chilis, and rapid pulse, there are localized pain and tender- 
ness, vomiting, and embarrassed respiration. There may be bulging of 
the tissues on the side in which the abscess is located. Sometimes a suc- 
cussion sound may be elicited. If the abscess contains air, there will be 
an area of tympanitic percussion sound between the liver and lung. As- 
piration under such conditions may bring forth foul smelling air instead of 
pus. Often a swelling with local oedema is noticeable. A friction sound 
may be heard over the complementary pleural space (9th to 11th rib). 
If there is much pus, the liver dulness will extend unduly upward. Similar 
phenomena will be elicited on the left side, minus the liver dulness. Eventu- 
ally the subphrenic abscess may rupture into the thoracic cavity and com- 
municate with a bronchus. In suspected cases aspiration should be done 
in the 7th or 8th interspace in the mid-axillary line or immediately above 
the supposed liver dulness. 

Prognosis. — The prognosis is grave. Early recognition and prompt 
operation and drainage may save life. Incision should be made over the 
centre of the dull area or wherever the probatory puncture reveals pus or 
foul air. As a rule a resection of the 8th, 9th, or 10th rib in the mid-axillary 
line will be indicated, or an incision in the interspace between the 7th and 
8th ribs in the anterior axillary line. Should this lead into the free thoracic 
cavity, a second puncture downward may be made in order to locate the pus. 



CHRONIC PERITONITIS 

The peritonaeum may participate in the chronic inflammatory condition 
of organs in contact with it (localized chronic peritonitis) and may suffer 
by reason of chronic infection of the serous membrane itself, resulting in 
diffuse adhesive peritonitis. Apart from cancer and tuberculosis, a pro- 
Uferative chronic peritonitis is described by Osier, which is found in chronic 
alcoholism and possibly in syphilis. 



332 THE DIGESTIVE SYSTEM 

The symptoms are persistent abdominal pain of a colicky character 
and occasionally intestinal obstruction due to fibrous bands. On opening 
the abdomen in such cases, the coils of the intestines are found matted 
together, the peritonseum is thickened, the omentum forms thickened masses, 
and a serous effusion may be present. 

The most interesting form of chronic peritonitis is the tuberculous variety, 
which is seen more often in children ' and is described in the psediatric 
section of this book. 



CANCER OF THE PERITONAEUM AND OMENTUM 

This is usually secondary to malignant disease of the abdominal or 
pelvic organs, and is observed in persons past middle life. There is per- 
sistent ascites or bloody effusion, with loss of flesh and cachexia, and large 
nodules are felt on palpation. 

Differential Points. — Tuberculous peritonitis occurs mainly in children. 
In hydatid disease booklets may be found in the puncture fluid. In doubtful 
cases an exploratory laparotomy is to be done. Cancer of the peritonaeum 
is incurable. Morphine and opium should be given to allay the pain. 



THE OMENTUM AND MESENTERY 

These structures frequently participate in whatever befalls the peri- 
tonaeum, and thus we observe syphilis, tuberculosis, and cancer of the 
omentum, the diagnostic features of which have been discussed. 

Cysts of the Omentum or Mesentery containing a brownish fluid have 
been observed. Hydatid cysts are rare. 

The TREATMENT is by aspiration and laparotomy. 

Thrombosis of mesenteric blood vessels gives symptoms of peritonitis. 

MESENTERIC AND RETROPERITONEAL GLANDS 

The lymph nodes in this region may become acutely inflamed or may 
undergo tuberculous, syphilitic, or malignant degeneration. 

Tabes Mesenterica, a tuberculous glandular enlargement, presents a 
distinct clinical picture and may be associated with tuberculosis of the 
peritonseum and intestine. Children suffering from this disease are puny, 
anaemic, and wasted, with a large tympanitic abdomen, diarrhoea, and 
fever. In cases difficult to diagnosticate the tuberculin test may be em- 
ployed. A blood examination is of value, also a temperature record ex- 
tending over two to three weeks. Indentable scybala should not be 
mistaken for enlarged glands. 

The prognosis is uncertain. 

The treatment is that of tuberculosis in general. 



CHAPTER XI 

THE CIRCULATORY SYSTEM 

Synopsis: Remarks on the Clinical Pathology of the Circulation. — Congenital Heart De- 
fects. — Clinical Aspects of Hypertrophy and Dilatation. — Acute Circulatory Failure 
(Heart Strain, Shock, Collapse). — Endocarditis. — Pericarditis. — Pericardial Adhe- 
sions. (Continued in Next Section.) 

REMARKS ON THE CLINICAL PATHOLOGY OF THE 
CIRCULATION 

An efficient circulation is of fundamental importance to the organism 
and depends upon the condition of the motor (heart) and the elasticity 
of the vessels. Vasomotor influence is exerted in such a manner that nor- 
mally one organ may be hyperaemic and another anaemic without disturbing 
the general circulation. There is also an aspirating mechanism furnished 
by the right heart and the lungs, supplemented by the contractions of 
muscles and fasciae. Owing to a well recognized reserve power, the accom- 
modation of the heart muscle to the various demands made upon it is very 
complete in health. Great and continued expenditure of force is followed 
by hypertrophy of tissue, just as in the skeletal muscles. Thus, any im- 
pediment to the circulation, be it located in lungs, kidneys, liver, or blood 
vessels, will put a strain upon the heart and produce hypertrophy, that is, 
more heart muscle, in order to overcome the resistance. The so called 
reserve power in the heart is present in hypertrophic hearts as well as in 
normal hearts, although not in the same degree. When arterial pressure is 
permanently increased, there is danger of rupture of capillaries (on exer- 
tion), particularly in arteriosclerosis. 

Unusual heart fatigue and heart strain may be followed by distention 
or dilatation of the heart. Recovery from distention may take place sooner 
or later, but occasionally a heart is thus permanently damaged. Heart 
strain is particularly dangerous in chronic degeneration of the heart muscle 
or following acute infectious fevers, such as typhoid or diphtheria, and in 
pertussis, etc. 

The position and size of the heart are made out by means of inspection, 
percussion, palpation, auscultation, and direct vision through the agency of 
X rays. Such knowledge must be acquired at the bedside and cannot be 
learned from books. In transposition of the viscera the heart is sometimes 
located on the right side (dextrocardia). In a rhachitic thorax the position 
and size of the heart cannot be judged if the left nipple is taken as a guide. 
In such cases it is best to take our measurements from the midsternal line. 

The lungs cover the heart and large blood vessels, excepting a part of 
the right ventricle. The area of the uncovered heart is called the area 

333 



334 THE CIRCULATORY SYSTEM 

of superficial dulness; that of the whole heart, the area of deep dulness. 
The heart is movable. Thus, the apex beat and heart dulness will move 
to the left if the patient's body during examination tilts to the left side; 
and it does not always mean enlargement if the apex beat is to the left of 
the nipple. In many people no apex beat, or heart shock, is felt. The 
term cardioptosis is occasionally used in connection with a heart which 
by reason of a laxity of attachment is very movable. 

In order to determine the borders of the heart, the lungs and pleura 
must be clear. The diameter of the heart is greater during forced expira- 
tion than during inspiration. The size and position of the heart and the 
decrease in size of a dilated heart improving under treatment may be 
observed by means of the Rontgen rays. 

The pulse should be felt at both wrists to see if it is synchronous. 
Auscultation of the heart and examination of the pulse at the same time 
will distinguish between systolic and diastolic phenomena. The pulse 
may be slow, rapid, intermittent, arrhythmic, small, large, or trip hammer. 
An imperfect heart systole may manifest itself as an intermittent pulse. 

Murmurs. — Regarding murmurs, it may be remarked that not all sys- 
tolic murmurs mean a valvular lesion, and thus we speak of accidental 
murmurs and of functional murmurs. We hear musical, rough, soft, 
blowing, scraping, and vibratory murmurs. In children accidental murmurs 
are comparatively rare. 

Accidental heart murmurs are as a rule systolic and offer no direct 
indications for treatment, as they are not connected with organic changes 
in the valves, papillary muscles, or chordae tendineae. 

Diminution of heart pressure and transitory disturbances of the motor 
function of the heart may cause temporary insufficiency of a valve and 
produce a heart murmur (functional murmur). 

Pericardial friction sounds may be mistaken for heart murmurs. A 
murmur may make its appearance during illness and subsequently disappear 
completely. Heart murmurs which disappear on holding the breath are 
of cardiopulmonary origin, and not endocardial. 

When the heart beats rapidly, as in fever, heart murmurs may disappear 
or accidental murmurs may arise; therefore, heart sedatives may be given 
for diagnostic purposes to reduce the forcible and rapid action of the heart 
and bring out murmurs if present. A murmur that accompanies the normal 
heart sound is of less gravity than one that replaces it. 

The pulmonic second sound is accentuated when there is pressure behind 
the valve, but such phenomena are also observed in the normal hearts of 
neurotic individuals. 

Reduplication of the sound indicates that valve action is not simul- 
taneous or is out of time, or the heart strain is present (nephritis). A 
reduplication of the first sound is frequently heard when there is high 
arterial tension, as in aortic stenosis or kidney disease. 

The most satisfactory way of auscultation is the direct one. The 
stethoscope is an aid to the dull ear, however. 

As the size of the liver and its tenderness are important guides to the 
degree of venous stasis, they should always be ascertained in connection 
with an examination of the heart, as also the examination of urine. When 



INFLUENCE OF A WEAK HEART ON THE CIRCULATION 335 

albumin and casts are found in heart insufficiency it becomes important to 
know which is primary, the heart or kidney trouble. This may be ascertained 
by a careful weighing of all the evidence, and thus the treatment will be 
better directed. 

In heart weakness, or insufficiency, a complicating hydrothorax is often 
present and overlooked. The removal of fluid from the thorax in cases of 
overwhelming heart strain is often followed by subjective relief and lasting 
improvement. 

In children the heart beat is often rapid and occasionally intermittent, 
even in sleep, and the rapid pulse has not the same significance as in adults. 
A slow and irregular pulse, particularly following infectious disease, is of 
graver import in children and justifies a guarded prognosis. 

In speaking of murmurs the author prefers to use the terms systolic 
and diastolic, not being convinced of any gain in clinical clearness by using 
the term presystolic. 

Summary. — The influence of a weak heart on the general circulation 
may be summed up as follows: When both sides of the heart are equally 
or unequally reduced in tone and power, we observe venous stasis with at 
first functional disturbance in the lungs, liver, kidneys, stomach, and 
brain, with their train of symptoms: Dyspepsia, dyspncea, local pain, 
vertigo, palpitation, etc., with a terminal dilatation and collapse of the 
heart. Whereas a moderate valvular defect is of importance as regards 
accommodation, a dilatation has a serious pathological importance. Venous 
stasis gives a well recognized clinical picture. Cyanosis and turgid veins, 
with and without pulsation of the jugular and other veins, cardiac dyspnoea, 
and hypersemia of the liver and lungs, with a tendency to catarrh and htemor- 
rhage and fluid accumulations in dependent parts and cavities, are the 
components of venous stasis. Cardiac dyspnoea is probably due to sw^elling 
and rigidity of lung substance from congestion. 

Heart insufficiency, or heart weakness, may be due to muscular insuffi- 
ciency or valvular insufficiency or to both combined. 

It may be primary or secondary to other diseased conditions which 
obstruct the circulation. This distinction has clinical importance, and if 
the underlying cause of circulatory weakness, or heart strain, can be re- 
moved, the heart may regain its integrity. 

In dealing with the patient the terms "weak heart" and "faulty cir- 
cxdation " are preferable to the terms heart disease or valvular heart disease, 
from the humane standpoint. The element of fear of sudden death which we 
find in the laity when heart disease is spoken of plays an important part 
in the management of such cases, and the physician may be well aw^are 
of the exact anatomical nature of the disturbance without unnecessarily 
alarming and harming his patient. 

CONGENITAL HEART DEFECTS 

Children are born with divers heart lesions, such as patency of the 
foramen ovale, patency of the ductus arteriosus, defect in the ventricular sep- 
tum, and lesions at the pulmonary orifice. Prematurity seems to be an 
etiological factor. 



336 THE CIRCULATORY SYSTEM 

Symptoms. — Cyanosis, dyspnoea, cough, convulsions, oedema, and great 
restlessness. In some cases murmurs or intermittent murmurs and an in- 
crease of the dull area of the heart are found on examination. In other cases 
the physical examination is almost negative. Cyanosis is not always present. 

Treatment. — We are unable to cure an anatomical defect of the heart. 
When blue babies, by reason of constant suffering, cry day and night, it 
is necessary to administer a sedative, such as chloral hydrate and potassium 
bromide, to put the child to sleep, and use as occasion demands. Some 
of these patients die during infancy, others succumb to some intercurrent 
disease during childhood, and some grow to maturity. 



CLINICAL ASPECT OF HYPERTROPHY AND DILATATION 

ENLARGEMENT OF THE HEART 

Enlargement of the heart may be due to simple hypertrophy or to 
dilatation or to hypertrophy and dilatation combined. 

Simple hypertrophy of the heart is the direct result of heart strain on 
a heart muscle not markedly degenerated, and it depends upon three factors: 
The duration of the strain, the degree of the strain, and the condition of 
the heart muscle. 

Enlargement may affect the entire organ or one side or only one chamber. 
The changes are most frequent in the left ventricle, because it does the 
principal work in pumping the blood through the body. 

We speak of a primary, or idiopathic, hypertrophy, when it occurs in 
neurotic individuals who have a continued rapid action of the heart fol- 
lowing the abuse of tobacco, beer, or prolonged heavy work (athletes) 
and in gravidity. Any strain upon a skeletal muscle makes it hypertrophic; 
it is just so with the heart muscle. 

We distinguish eccentric and general hypertrophy. Idiopathic hyper- 
trophy is a specimen of general enlargement. 

Hypertrophy is frequently secondary to arteriosclerosis, nephritis, hepa- 
titis, emphysema, pericardial adhesions, and valvular defects; in fact, any 
chronic obstruction to the circulation is followed primarily by hypertrophy, 
which influences its function and ends in dilatation of the heart muscle. 

In ordinary hypertrophy the heart weighs from 500 to 600 grammes. 
Weights up to 1,500 grammes have been reported, but they are rare. 

Symptoms and Physical Signs. — Hypertrophy is a conservative process 
and often gives no symptoms, but frequently there is a sense of fulness, with 
flushing, headache, palpitation, and forcible shock without palpitation. In 
arterial degeneration with hypertrophy of the heart the development of 
miliary aneurysm in the brain and cerebral haemorrhage is common. There 
may be bulging of the pericardium, the area of impulse is increased, and 
percussion shows increased dulness going to the left of the nipple. This may 
be absent, however, if hypertrophy increases the heart in the anteroposterior 
diameter. The pulse is full, strong, and of high tension in cardiac hyper- 
trophy. Enlargement of the heart must be distinguished from mediastinal 
growths, neurotic palpitation, and hydropericardium. Chronic pneumonia 
and pleurisy on the left side, by reason of retraction, may " uncover " the 



HYPERTROPHY AND DILATATION OF THE HEART 



337 



heart and give rise to an extensive area of dulness, which may be mistaken 
for hypertrophy. The latter is difficult to make out in a deformed chest. 

A strong, heavy impulse and apex beat denotes hypertrophy. In peri- 
cardial effusion the heart shock is not visible and is not felt. The sounds 
are distant and muffled. 

Cardiac hypertrophy is clinically divided into three stages: The period 
of development, the period of compensation, and the period of decompensa- 
tion (acute and chronic by dilatation). 

Prognosis is a matter of retained compensation. Hypertrophy may 
be transient from transient causes, such as neurotic palpitation, tobacco, 
and overexertion, and will require sedative treatment, as with bromide of 
sodium and laxatives. 

Hypertrophy and arteriosclerosis will require careful dietetic and hygi- 
enic management in order to prevent, if possible, apoplexy. Otherwise, 




Fig. 115. — Dulness in Hypektbophy of the Left Ventricle. 

Apex beat heaving and carried dowii and to the left, perhaps outside of the apex outline. 

Apex pointed. (Butler.) 

hypertrophy should be looked upon as a conservative process of nature, 
and our therapeutic indications are directed to the underlying cause and 
to the prevention of dilatation of the hypertrophic heart muscle. 



DILATATION OF THE HEART 



High blood pressure and impaired resistance produce dilatation of the 
heart. Two varieties are recognized: Dilatation with thickening and dila- 
tation with thinning of the heart walls. 

Sudden cardiac failure during exertion is due to dilatation of the heart 
or rupture of a valve. Hearts which have lost their tone from muscular 
degeneration (infectious fevers or valvular defects), if subjected to severe 
strain, are apt to dilate. Mental emotion is supposed to be one of the causes 
of idiopathic dilatation. In pericardial adhesions the heart is apt to dilate. 
Dilatation is the opposite of hypertrophy and causes heart weakness. 



338 THE CIRCULATORY SYSTEM 

Physical Signs. — Diffused impulse, weak muffled sounds. Dilatation 
may be accompanied by a murmur, and the heart sounds may be absent. 
The pulse is small, weak, quick, and intermittent. On auscultation we 
hear embryocardia, or gallop rhythm. Murmurs formerly present may 
disappear and murmurs may set in and disappear as the heart becomes 
stronger. This is due to relative insufficiency, not to valvular lesion. One 
of the earliest signs of dilatation is an irregular and intermittent pulse. 

Hypertrophy and dilatation are often due to overexertion and alcohol, 
as in heavy beer drinkers. 

During severe muscular effort, when the heart is strained to its utmost, 
as in mountain climbino;. acute dilatation may result. A sense of distress is 




Fig. 116. — Showing the Dulness due to Dilatation and Hypertrophy of Both 

Ventricles. 
Apex rounded and apex beat diffused. (Butler.) 

felt and a feeling of dyspnoea, which may pass over after a day's rest or 
may reassert itself on the slightest exertion. We speak of such a person as 
"wind broken." 

Dilatation of the right heart may be recognized by the location of the 
impulse, which is below or to the right of the ensiform cartilage. The apex 
beat may be absent on the left side. Pulsation to the right or left of the 
sternum in the second and third interspace is looked upon as an evidence 
of auricular dilatation. 

The management of circulatory failure due to dilatation of the heart 
will be considered in the chapter on Valvular Heart Disease. 

In acute dilatation from overstrain absolute rest in bed must be enjoined. 



ACUTE CIRCULATORY FAILURE (HEART STRAIN, SHOCK, 
COLLAPSE, RUPTURE) 

A sound and a damaged heart may suffer acutely in various ways, viz. : 
from direct injury, embarrassment due to compressed or rareiEied air, entrance 
of air into the right heart, embolism of the pulmonary artery, severe hsemor- 



ACUTE AND CHRONIC ENDOCARDITIS 



339 



rhage, shock or nervous depression, and the various septic and chemicai 
poisons, anaesthesia, and mechanical obstruction to the heart's action from 
pericardial effusion. It is nothing unusual for a senile heart to come to a 
stop from shock or from the effects of an operation or from an attack of 
acute gastroenteritis. A sudden heart death in convalescence following 
septic diphtheria is no uncommon circumstance. 

The heart's nourishment depends so much upon its own proper function 
that any depressing circumstance which lowers the blood pressure in the 
aorta and coronary arteries may be of great moment. The rapidity with 
which sudden circulatory fail- 
ure sets in gives the patient 
barely time to state his dis- 
tress; consciousness fails, the 
face turns blue, the extremi- 
ties are cold, the pulse fails, 
and death supervenes some- 
times in a convulsive seizure. 
In subacute cases the collapse 
passes over and the circula- 
tion under proper manage- 
ment gradually improves. 

The treatment of acute 
collapse is its timely preven- 
tion, of which we shall speak 
under the management of the 
various diseases which pro- 
voke it. In cases of acute 
collapse in which death is not 
instantaneous the prompt at- 
tention of the physician may 
save life. Lower the head, 
loosen the clothes, employ ar- 
tificial respiration, hold am- 
monia to the nose, give salt 

water hypodermically or per rectum, or administer strychnine, camphor, 
whiskey, and digitalis internally or hypodermically (see chapter on General 
Therapeutic Management). The gradual progressive insufficiency of the 
heart noticeable in so many diseases is best combated by absolute rest 
and such other measures as are discussed under their various headings. 




Fig, 117. 



Rupture of the Heart (Dr. 11. H. 
Newton). 



ENDOCARDITIS 

Endocarditis is an inflammation of the inner (lining) membrane of the 
heart. Rheumatism or any other infectious disease may constitute the 
causative factor. We distinguish acute and chronic endocarditis. 



ACUTE ENDOCARDITIS 

Acute endocarditis is recognized clinically as simple, malignant, septic, 
and verrucose. The simple form is one of the associated features of acute 



340 THE CIRCULATORY SYSTEM 

rheumatic fever, and is occasionally met with in scarlet fever, so called 
tonsillitis, typhoid fever, pneumonia, and chorea. 

Bacteria, the causative factor of infection, for some reason or other 
find a foothold on the endocardium, usually in the left heart, and the ensuing 
hyperplastic or destructive inflammatory process is very apt to result in 
permanent damage to the valves of the heart. 

A somewhat similar but much severer form of endocarditis occasionally 
follows gonorrhoeal infection or gonorrhoeal rheumatism. The most fatal 
form is septic or ulcerating endocarditis, all forms presenting but different 
degrees of intensity of the same process, but possibly of different microbial 
origin. The lesions are vegetative, ulcerative, or suppurative, and the 
sequelae are embolism and infection of other tissues and organs. 

Diagnosis. — There is nothing characteristic in an onset of endocarditis. 
When in the course of rheumatic arthritis there is an exacerbation of fever, 
with a rapid, unsteady heart, with or without increase of joint symptoms, 
endocarditis may be suspected. If, in addition, a murmur is now heard in 
a heart which was free before, we are very apt to diagnosticate endocarditis, 
bearing in mind, however, that accidental murmurs are heard over the heart 
during febrile disease, but may disappear and leave an intact heart. There 
may be sweating, chills, delirium, petechise, and embolic processes, with 
the symptoms pertaining to them, such as coma, paralysis, local pain in 
some other organ, bloody sputum, bloody urine, and retinal haemorrhage, 
or localized gangrene. 

Some types of endocarditis, particularly the chronic form, resemble 
irregular intermittent fever. Others have the cardiac or cerebrospinal 
symptoms pronounced. Jaundice has been observed, also oppression and 
short breathing, cardiac pain, and great restlessness. Each case must be 
judged upon its own merits, and no definite general diagnostic landmarks 
are possible. 

The acute septic form, which frequently terminates fatally, may com- 
plicate septicaemia from erysipelas, puerperal fever, and gonorrhoea. The 
milder forms usually recover with a damaged valve. One of the great 
achievements to be hoped for in practical medicine would be the prevention 
of endocarditis in chorea, eruptive and other fevers, gonorrhoea, tonsillitis, 
diphtheria, etc. 

Treatment. — Absolute rest; warm baths; cooling drinks; an ice bag to 
the heart. In the septic form the management is the same as for any 
other sepsis, viz., elimination and stimulation. Treatment by antistrep- 
tococcus serum is in its experimental stage. 

In acute articular rheumatism with high fever, rapid heart, and pro- 
nounced restlessness, it seems rational to combine a heart sedative with 
sodium salicylate as follows: 

I^ Sod. saUcyl., 5ij ; 

Potass, iodid., 5ss. ; 

Tinct. aconiti radio. , 1 __ 

Tinct. verat. virid., j ' ^ ' ' 

Aquae, q. s. ad. 5ij- 

M. S.: A teaspoonful, with sugar, every two hours, for children; 



PERICARDITIS 341 

the dose for adults must be larger. Apart from internal medication, 
Crede's ointment may be rubbed into the skin, 5j three times daily. 

It is, furthermore, of the utmost importance that in the treatment of 
rheumatic cases routine flushing of the bowel with warm saline solution 
be practised, in order to eliminate, if possible, the danger of intestinal 
toxaemia or secondary infection from the enteric tract. 

CHRONIC ENDOCARDITIS 

Chronic endocarditis is a slow, insidious process, secondary to acute 
endocarditis or superinduced by various irritants and infections, such as 
syphilis, gout, alcohol, and malaria — together with prolonged muscular 
strain. This process results in thickening and contraction of valves, 
usually in the left heart. It may be observed in children and it is common 
in middle aged individuals. When the valves are affected and the heart's 
equilibrium is disturbed, the first complaints are heard, and subsequently 
the course and management are those of chronic valvular disease. Al- 
coholism, syphilis, malaria, and rheumatic infection are the predisposing 
factors. Syphilis and malaria require specific treatment and change of 
climate. Persons living in unwholesome abodes must be told that sunshine, 
cleanliness, and fresh air are the best preventives against acute and chronic 
infection. 

PERICARDITIS 

Definition and .etiology. — Pericarditis is an infection and inflammation 
of the pericardium, usually secondary to an inflammatory process of a 
neighboring serous membrane. As in pleurisy, we have a dry pericarditis 
or one with serous or purulent effusion with and without adhesions. 
Rheumatism, all forms of sepsis, the eruptive fevers, Bright's disease, 
typhoid fever, diabetes, scurvy, and tuberculosis are provocative of peri- 
carditis. 

Pericarditis is not rare in children as a sequel of rheumatism or scarlet 
fever. 

Dry pericarditis is recognized principally by its friction sound, to and 
fro, corresponding to the systole and diastole of the heart. This friction 
sound is superficial and close to the ear, and there are no definite lines of 
transmission, as in endocardial murmurs, although it must be admitted 
that occasionally it is difficult to distinguish a friction sound from a double 
murmur. Dry pericarditis is of limited duration, but it may persist and 
result in a chronic thickening of both layers of the pericardium. There 
is no typical fever curve in this ailment. 

Pericarditis with effusion may develop without characteristic signs, 
although prsecordial distress, pain on pressure over the heart, and dyspnoea 
are the rational symptoms. Patients so afflicted have an anxious counte- 
nance with a paradoxical pulse, which becomes lost or faint during inspira- 
tion. These symptoms are the direct result of embarrassed heart's action. 
From pressure upon the trachea and oesophagus we may have aphonia, 
cough, dysphagia, and venous stasis. Insomnia, delirium, and coma are 
observed in severe cases. 



342 



THE CIRCULATORY SYSTEM 



The 'physical signs of massive pericardial effusion are bulging of the chest 
and of the intercostal spaces, occasionally oedema of the chest wall, diminu- 
tion and obliteration of the cardiac shock, dislocation and loss of the apex 
beat, and an irregular, pear-shaped increasing heart dulness, with a broad 
downward base. With absorption of the fluid the friction sounds return. 
When an onset of pericarditis is suspected, the heart dulness should be 
carefully marked with a blue pencil. Pericarditis is often overlooked or 
mistaken for pleurisy. 

The prognosis depends upon the underlying cause and is favorable in 
the simple variety. Septic cases are usually fatal ; the purulent variety 




Fig. 118. — The Triangular Area of Dulness Due to a Large Pericardial Effusion is 
Shown by the Outer Solid Line. 



For comparison the normal cardiac dulness is shown by the inner shaded area, 
of apex beat with reference to the pericardial dulness. (Butler.) 



Note position 



not necessarily so, as the pus may be absorbed or is amenable to surgical 
interference. 

Differential Points. — It is sometimes extremely difficult to discriminate 
between dilatation of the heart and pericarditis with effusion. Cases occur 
in children in which it is difficult to distinguish between encapsulated pleu- 
ritic effusion and pericarditis and effusion, the needle showing a serosan- 
guinolent fluid. Cases have been reported in which purulent pericarditis 
was mistaken for encapsulated empyema. 

Hydropericardium (Dropsy of the Pericardium) occurs in connection 
with general dropsy and presents the signs of pericarditis with effusion. 
Chylo pericardium is a term used in cases of chylous effusion. Hoemoperi- 
cardium may result from rupture of an aneurysm or from injury. Pneumo- 
pericardium may result from a stab wound, etc. 

Treatment of Pericarditis. — A stiff dose of calomel and jalap is appro- 
priate at the start of almost any ailment. Rest in bed should be enforced. 
An ice bag to the heart or a blister or dry cupping is indicated. In adults 
complaining of severe pain a morphine injection over the seat of pain may 
be advisable. Crede's silver ointment (15 per cent of silver to one ounce 



ADHERENT PERICARDIUM 343 

of fat) may be used to counteract sepsis. It is administered by inunction, 
5j ter in die. 

If syphilis or malaria is suspected as an underlying cause, potassium 
iodide may be administered by the rectum, or a few doses of quinine may 
be given by the mouth. The salicylates are indicated when a rheumatic 
origin is the most plausible. The fewer drugs, the better for the patient. 
Five drops of dilute hydrochloric acid in sweetened water, after eating, 
will aid digestion. The diet must be light with plenty of water. Feverish 
patients generally enjoy a warm bath. In massive effusion, with severe 
pressure symptoms, aspiration may be necessary with subsequent incision 
and drainage if pus or s6ropus is found. The puncture should be made in 
the fourth or fifth interspace, one to one and a half inches to the left of the 
sternal margin (see article on Dropsy and Effusion). 

Suppurative pericarditis secondary to pleuropneumonia, empyema, 
osteomyelitis, and other septic processes, typhoid fever, influenza, trauma, 
etc., requires surgical treatment. The mortality is about 60 per cent. 
Resection of a portion of the fifth rib under local or general anaesthesia 
is the proper procedure. Puncture is not sufficient. 

ADHERENT PERICARDIUM; CHRONIC ADHERENT PERICARDIUM 

Pericarditis with adhesions which hamper the heart's action. 

Symptoms.— Systolic depression of the intercostal spaces and fixation 
of the apex beat. In adhesions between the pericardium and chest wall 
the area of cardiac dulness remains the same on inspiration and expiration, 
and the. heart is usually enlarged. Adherent pericardium may be universal 
or partial, following pericarditis of all forms. The symptoms are indefinite, 
although in children, with their flexible thorax, systolic retraction of the 
apex region with diastolic rebound and diastolic collapse of cervical veins 
is noticed. Accidental blubbering murmurs are also heard and the pulsus 
paradoxus is observed. Adherent pericardium is sometimes associated 
with a systolic retraction in the eighth or ninth interspace on the left side 
posteriorly (Broadbent's sign). 

Treatment. — Nothing in the way of irritating restrictions should be in- 
flicted on the patient. Apart from constitutional treatment nothing can 
be done. 



23 



CHAPTER XII 

THE CIRCULATORY SYBTEM— Continued 

MUSCULAR AND VALVULAR INSUFFICIENCY OF THE 
HEART AND HEART NEUROSES 

Synopsis: Weak and Flabby Heart. — Fat Laden Heart. — Degeneration of the Heart 
Muscle without Valvular Defects: Senile, Gouty, Syphilitic, Fatty, Fibroid Heart, 
Myocarditis with Constant Arrhythmia. — Valvular Heart Disease and Muscular In- 
sufficiency — Heart Neuroses. 

WEAK HEART; CONGENITALLY SMALL HEART; FLABBY HEART MUSCLE 

It is a well known clinical fact that some individuals have a small heart; 
thus, most people with tuberculosis or tuberculous tendencies have small 
hearts. It goes without saying that persons not afflicted with tuberculosis 
may have a small heart. Such persons look anaemic, are easily tired, and 
have palpitation on slight exertion, particularly if they increase in weight. 
These patients present all the clinical evidence of moderate heart insuffi- 
ciency, and may show a slight puffiness at the ankles. 

The diagnosis is made by exclusion. So called "neurasthenic " heart 
weakness with its long train of symptoms is often nothing more than motor 
weakness. 

Treatment. — An insufficient heart which will stand a strain will improve 
by reason of such strain and increase in motor force; therefore it is the 
duty of the physician to overrule the laziness and indolence of that class 
of patients whose heart symptoms are not due to degenerative processes 
by ordering active exercise. It must be explained to the patient that pal- 
pitation and moderate dyspnoea do not contraindicate active exercise. 
This must be particularly impressed upon corpulent women who feel faint, 
dizzy, and languid after exertion and are very prone to accept rest instead 
of motion. It is in this class of cases that graded climbing, outdoor and 
indoor exercise and gymnastics, and a judicious dietary will work wonders. 
The details of such management will be discussed under Fat Laden Heart. 

Weak heart from cardioptosis is described as a relaxation of the elastic 
tissue of the large vessels which allows the heart to prolapse, that is, hang 
much lower in the thorax than normal. This prolapse causes the apex 
beat to appear beyond the nipple line, and makes the lower part of the area 
of relative and absolute heart dulness much wider than normal. The 
pathognomonic sign of the existence of this anomalous condition is the 
absence of heart dulness at the ordinary upper limit of the organ. As the 
result of the cardioptosis such symptoms as respiratory anguish, painful 
344 



THE FAT LADEN HEART.— SPECIMEN DIET IN OBESITY 345 

dyspnoea, and prsecordial discomfort develop. Some of the cases of angina 
pectoris are said to be due to this condition. The cause is always an hered- 
itary tendency to relaxation of tissues and seems to be a family trait. 
Apart from general tonic management there is no special treatment for such 
a condition. 

THE FAT LADEN HEART (COR ADIPOSUM) 

Fat people frequently present the clinical evidence of heart weakness, 
and in the absence of a murmur, we are apt to diagnosticate "fatty heart." 
In all such cases we must endeavor to distinguish between fatty degenera- 
tion and the fat laden heart of obesity. In obesity and fat laden heart 
much can be done by rational management. Corpulent individuals are 
sluggish in their movements. They have dyspepsia from mechanical 
interference with respiration, later on from true fatty infiltration of the 
heart muscle; the liver becomes large and fatty. CEdema, intertrigo, and 
eczema increase the suffering of the patient. 

Treatment. — The indications for treatment are reduction of the amount 
of food and oxidation of the fat already stored. Persons who have a tendency 
to corpulency should be warned in time. To reduce weight we have the 
Banting, Ebstein, Schwenninger, and Oertel systems (see Nutrition and 
Diet). The latter regulates diet and gives attention to the heart and 
circulation by systematic exercise, and is as follows: 

Oertel recognizes two classes of cases: 1. Corpulency without respira- 
tory and circulatory disturbance. 2. Corpulency with respiratory and 
circulatory disturbance. The oxidation of fat in the body is accomplished 
by massage, exercise in a gymnasium or in the open air, walking, mountain 
climbing, cycling, horseback riding, rowing, using the punching bag, playing 
tennis, etc. Turkish baths may be used, also the purgative waters of 
Carlsbad, Marienbad, Vichy, and Kissengen or their salts. Liquids should 
be restricted and none taken with a meal. Turkish baths and violent 
exercise are contraindicated when the heart is damaged, as in the second 
class of cases. Walking is the best exercise, and climbing must be done 
gradually (terrain cure of Oertel). 

Thyreoid treatment, probably by increasing oxidation, has given good 
results in a number of cases of obesity. From 3 to 5 grains of the dry pow- 
dered gland may be given three times a day. Should palpitation and 
disturbance of the cardiac rhythm supervene, its use must be stopped, 
but dieting and exercise should be continued. 

SPECIMEN DIET IN OBESITY 

A. M. — Six ounces of coffee or tea, 3 ounces of bread. 

Noon. — Eight ounces of meat or fish of any kind, salad, vegetables, 
2 ounces, fruit, 3 to 6 ounces, bread or pudding, 3 ounces; wine for those 
who are accustomed to it, but no beer. 

Evening. — Two eggs, 4 ounces of ham or raw meat, bread, cheese, salad, 
fruit, tea or coffee. 

Water is to be taken between meals. The diet should be generous as 
to variation. The menu should be liberal in quality, but the quantity 



346 THE CIRCULATORY SYSTEM 

should not exceed 2,000 calories. One should eat one third less than under 
ordinary circumstances and not attempt to reduce fat by a special kind 
of food. The same rule holds good for children. In corpulency with the 
muscles or valves damaged, and as the consequence, congestion in various 
organs or arteriosclerotic changes, the greatest care must be taken in 
advising exercise. The physician must feel his way, so to say, and not 
force the patient into a regimen which may bring him into danger from 
bursting of a capillary vessel or from acute dilatation of the heart. Good 
common sense will direct the management, which can only be outlined in 
the absence of a specific case. 

The total daily amount of water should be limited to from 36 to 48 
ounces (including tea, coffee, and wine), except in very hot weather, when 
more can be taken. Sweets of all kinds are to be avoided as much as possible. 

CHRONIC DEGENERATION OF THE HEART MUSCLE NOT DUE TO 

VALVULAR DEFECTS 

Various terms are used to designate such condition, viz.: Senile heart, 
gouty heart, syphilitic heart, myocarditis with constant arrhythmia, fatty 
degeneration, fibroid heart, etc. 

Any acute infection, such as diphtheria, typhoid or rheumatic fever, 
scarlatina, etc., may be the starting point of the chronic inflammatory 
process in the heart muscle. Chronic infections, such as syphilis and 
malaria, are causative factors; and gout, diabetes, atheroma, alcoholism, 
pernicious anaemia, chronic intestinal putrefaction, toxaemia, and overwork 
are frequent causes. In fact, any nutritional change which blocks up 
the blood supply of the heart may result in softening and degeneration 
of the heart walls. The chronic form generally supervenes upon sclerosis 
of the coronary arteries. They are terminal arteries, and become blocked 
with a gradual onset. 

Anatomically we observe induration, softening, calcareous, hyaline, 
fatty, and amyloid degeneration with general or localized dilatation. 
Clinically we cannot distinguish one form of degeneration from the other, 
their symptoms being alike. 

Symptoms of Muscular Degeneration of Whatever Nature. — Dyspepsia; 
palpitation; praecordial distress; arrhythmia; anginoid, syncopal, apoplectic, 
or epileptoid attacks; a short, unsustained, rapid, or regular or irregular 
pulse; cold extremities; dropsy; and great weakness. The heart eventually 
dilates, and a murmur may be heard, due to ventricular dilatation. Sudden 
death after a full meal is not infrequent. 

The area of the heart dulness may be normal unless degeneration has 
affected a hypertrophic heart. Attacks of aphasia often present themselves 
when sclerosis is present. 

Prognosis. — We cannot cure this condition, but by careful management 
we may prolong life for an indefinite time. A person with myocarditis 
may drop dead suddenly or live for many years. 

THE SENILE HEART AND ARTERIOSCLEROSIS 

In late life and without any history of previous disease the heart is 
often found enlarged, and an active or relative weakness of the myocar- 



VALVULAR HEART DISEASE 347 

dium is the origin of the symptoms of the senile heart, such as praecordial 
anxiety, unstable action, weak impulse, intermission of the beat, subjective 
throbbing (which may be physical or emotional), cardiac asthma with and 
without exertion, tremor cordis, fluttering, loss of appetite, fainting, a 
feeling of weakness, albuminuria, and a feeling of insecurity. 

Senile diseases are always degenerative and tend to abridge the natural 
term of life, and our object is to relieve symptoms and check decadence. 
Senile cardiac failure is based upon impaired metabolism. 

Heart Insufficiency due to Syphilis belongs to the group. There are 
no special pathognomonic symptoms in heart syphilis; early symptoms 
are not pronounced. Its prevention is more readily accomplished than its 
cure. When the usual subjective symptoms bring the patient to the phy- 
sician and anamnestic data point to an underlying syphilis as a causative 
factor of myocardial weakness, an antiluetic regimen must be instituted. 
It is in this class of cases that potassium iodide is powerful for good. As 
the heart's action is increased and depressed by nervous influence, it is 
unwise to worry the patient by keeping him constantly under strict super- 
vision. 

Principles of Treatment of the Various Forms of Chronic Muscular De- 
generation. — The patient must be moderate in eating, drinking, and exercis- 
ing. No special diet is necessary (except in obesity). The food should 
be plain and whatever the patient may like, except Swiss cheese, pork (lean 
ham allowed), roast goose and duck, fatty sausage, pastry, rich dishes, 
hard vegetables, cabbage, sauerkraut, peas, white beans, string beans, and 
lentils. Beer should be forbidden as apt to produce flatulence and in- 
digestion. There should be five hours between meals, and the main meal 
should be in the middle of the day. Fluids should be taken sparingly 
between meals. A little whiskey in water is rather beneficial. Ginger 
ale is a good drink. Five to ten drops of dilute hydrochloric acid in water 
after meals will aid digestion. The patient may rest before and after eating. 
A mild smoke is not objectionable. The bowels should move daily. General 
massage is advisable. Venesection is often of great value. A warm, 
cleansing bath may be taken as often as necessary. Iodide of potassium 
is indicated in syphilitic myocarditis. The indications for heart drugs are 
discussed under Valvular Heart Disease. 



VALVULAR HEART DISEASE 

The heart is liable to functional and structural derangements, many 
of which can be recognized clinically, and among the latter the valvular 
defects play an important role. 

A valvular defect is of accommodative importance. A derangement in 
the mechanism of the cardiac valves places an obstacle in the way of the 
outward flow of blood. To maintain the circulation under these conditions, 
the heart necessarily enlarges by hypertrophy of the myocardium. As a 
sequel and correction of valvular insufficiency or obstruction Nature fur- 
nishes us with compensatory hypertrophy of the heart muscle, but muscular 
degeneration and dilatation manifest themselves earlier in the damaged heart 
than in the strong heart, and shorten the tenure of life. The action of the 



348 THE CIRCULATORY SYSTEM 

heart is increased and depressed by nervous influence; worry and anxiety 
act unfavorably upon the heart and particularly upon a damaged heart; 
therefore, don't worry the patient by keeping him continually under strict 
supervision and treatment. 

The various valvular defects do not influence or disturb the circulation 
in a like manner, but clinically this is more of prognostic than therapeutic 
import. We have no separate treatment for the individual sets of valves, 
and an exact valve diagnosis cannot always be made, nor is it absolutely 
necessary as regards treatment. Treatment really begins when the hyper- 
trophic heart muscle becomes insufficient and the heart is unable to empty 
itself. 

The estimation of valvular insufficiency or obstruction as a problem 
of hydrostatics is easier than the estimation of the loss of elasticity of muscle 
or the reserve power of the heart. The prognosis as to tenure of life in 
cardiac disease is therefore somewhat uncertain. 

Signs and Symptoms of Valvular Lesions 

Aortic Stenosis. — Systolic murmur in the aortic area at the right 
edge of the sternum, in the second or third space, is transmitted upward 
to the right sternoclavicular articulation or may be heard along the right 
edge of the sternum lower down; occasionally it is accompanied by a thrill, 
particularly if it follows rheumatic fever. Functional systolic murmurs 
in this region are also heard in anaemia, in anaemic individuals convalescent 
from acute illness; in impaired flexibility of a valve without stenosis in middle 
age, and in dilatation of the aorta just above the valves. 

The DIAGNOSIS will depend upon the history, the aspect, the age, and 
the absence or presence of concomitant symptoms. A loud murmur in- 
dicates strong ventricular action. In actual obstruction we observe cardiac 
hypertrophy and deranged circulation, and a low and forcible apex beat, 
the pulse wave being long and slow and the pulse small. In actual ob- 
struction of the aortic valve the mitral valve may suffer severe strain and 
become incompetent, which is a downward step in the evolution of the 
disease. 

The PROGNOSIS is not so serious as in aortic incompetence, but more 
serious than in mitral incompetence. Sudden death from it is improbable. 

Aortic Incompetence. — A diastolic murmur in the aortic area is some- 
times heard in the third left space and may be conducted downward to the 
apex. There is violent arterial pulsation, particularly in the carotid and 
brachial arteries. Pulsatile reddening of the skin is noticed when a red 
patch on the skin is brought out by friction. Capillary pulsation is also 
noticed from various causes, producing a low tension pulse. The pulse 
is a collapsing water hammer pulse (Corrigan), and has a peculiar double 
beat. In advanced cases the pulse is irregular and the aortic second 
sound, if looked for over the carotid in the neck, is absent. Concomitant 
stenosis modifies the pulse signs. There will be in addition to hypertrophy, 
dilatation of the left ventricle, with a marked apex beat displaced down- 
ward and to the left and lifting of the chest wall. Other symptoms are 
breathlessness, syncopal attacks, anginal attacks, and prsecordial pain. 
Sudden death is apt to occur. Mitral regurgitation may coexist. 



SIGNS AND SYMPTOMS OF VALVULAR LESIONS 349 

Prognosis. — When the lesion is not due to degenerative changes in 
the heart, and the signs and symptoms already enumerated are mild, the 
patient may enjoy life for many years, and much will depend upon age, 
habits, occupation, and the time of life when the lesion was acquired. 

Aortic insufficiency may be due to endocarditis, of syphilitic, rheumatic, 
or malarial origin, and possibly to prolonged strain (athlete's heart). A 
relative insufficiency due to dilatation of the aortic ring is rare. 

Mitral Regurgitation. — There is a systolic murmur at the apex or beyond 
the apex, toward the axilla, often heard at the back of the chest, between 
the scapula and the spine, a portion of the ventricle resting upon the spinal 
column. Occasionally the murmur is heard in the third or fourth space 
in the vertical nipple line. 

Differential Diagnosis. — A systolic aortic murmur is conducted 
toward the apex. A systolic tricuspid murmur, regurgitation, is lost to 
the left of the apex and heard between the apex and the lower end of the 
sternum. Spurious pulmonic murmurs due to compression of the edges 
of the lung by ventricular systole are not audible during expiration. 

The pulse in mitral regurgitation is usually irregular in rhythm and 
force, probably owing to varying pressure during inspiration and expiration. 
When a murmur is present and the first sound persists, the leakage at the 
valve may be slight. A loud murmur means a strong ventricle. A musical 
murmur is sometimes heard. The pulmonic second sound is accentuated, 
and hypertrophic dilatation of the right ventricle follows. The apex 
beat is displaced outward to the left with extension of the area of deep 
dulness. In slight regurgitation maximum symptoms are missing. In 
severe, advanced cases dyspepsia, dyspnoea, dropsy, and liver enlargement 
are present. 

Functional mitral incompetence without valvular disease may result 
from anaemia or acute febrile disease. Mitral murmurs are heard in debility 
and old age. 

Hcemocardiac murmurs are usually soft and blowing and do not replace 
the first sound. They are not conducted to the axilla or back, and there 
is no displacement of the apex beat. There are exceptions, however. The 
history of the case is important. Temporary regurgitation in acute rheu- 
matic fever is possible and does not invariably indicate valvular lesion. 
A mitral murmur associated with chorea and with antecedent rheumatism 
may be functional and temporary, or organic, and a lengthy observation 
is often necessary to come to a definite conclusion. Mitral regurgitation — 
incompetence — may be established imperceptibly in middle and old age, 
with and without organic valvular alteration. The regurgitation may be 
the same as in anamia and flabby heart (relative insufficiency) or may 
be due to an enlargement of the auriculoventricular opening from dilatation 
of the ventricle from some form of undue arterial tension. 

Prognosis. — This is the least serious and most amenable to treatment 
of all valvular lesions. Slight regurgitation permits of old age, and women 
may marry. Dropsy, pulmonary and hepatic congestion, and oedema 
come and go. 

Mitral Stenosis. — This is a more serious form of valvular disease, rela- 
tively frequent in women. The murmur is diastolic, the pulse is usually 



350 THE CIRCULATORY SYSTEM 

of high tension and regular until heart failure sets in, the heart is enlarged, 
and the apex beat is displaced to the left and downward in pronounced 
cases with powerful shock and thrill. The pulmonic second sound is 
accentuated from back pressure. Three stages may be observed in the 
evolution of mitral stenosis. In the first stage a diastolic murmur and 
diastolic sound are heard at the apex; in this stage no serious symptoms 
are observed. In the second stage the diastolic sound has disappeared 
and is replaced by a diastolic murmur. This is best distinguished from 
the systolic murmur of incompetence by feeling for the heart shock at the 
time of auscultation. A murmur synchronous with the heart impulse is 
systolic. If we listen at the heart during an attack of palpitation or tachy- 
cardia, all murmurs are indistinct, but reappear after the heart is quieted. 
In the third stage the diastolic murmur frequently disappears, and an exact 
diagnosis may be difficult. Other symptoms are breathlessness on exertion, 
dyspeptic symptoms and nausea with a tendency to congestion of the 
lungs, hsemoptysis and arterial embolism, and enlargement and pulsation 
of the liver. When decompensation sets in, in combined stenosis and 
regurgitation, the signs above mentioned fluctuate and the heart's action 
becomes irregular. 

Prognosis. — When mitral stenosis is established in childhood, the prog- 
nosis is more serious than when it is established at a later stage. When 
attacks of delirium cordis, or tachycardia, supervene in mitral stenosis, 
the patient's life is in great danger from acute pulmonary oedema. A 
marked case of this kind in the experience of the writer occurred in a young 
lady of twenty-four whose valvular lesion was acquired at the age of six 
during an attack of articular rheumatism. Without premonitory symptoms, 
" heart hurry " would manifest itself usually in the evening or after retiring. 
Within a short space of time rales could be heard all over the chest, a short 
cough set in, the dyspnoea became acute, foam issued from the mouth, 
and finally the patient became blue from carbonic acid intoxication and 
lay moaning in a stupor. The patient recovered from seven such attacks. 

When several valves are affected all sounds may disappear. 

Valvular lesions in children present no special difficulty in diagnosis. 
Dyspnoea on exertion, anaemia, a bluish tinge of the skin and mucosa, 
clubbed fingers in advanced cases, all forms of dropsy, and congestive symp- 
toms are found — headache, loss of appetite, liability to bronchitis, and 
bulging prsecordia. 

Tricuspid Incompetence and Stenosis, when pronounced, are usually 
congenital. 

Tricuspid Regurgitation, with or without a murmur, is usually due 
to back pressure in the lungs in valvular disease of the left ventricle. The 
murmur, if present, is systolic and heard to the left of the sternum in the 
vertical nipple line. It is often mistaken for a mitral regurgitant murmur. 
The veins of the neck are distended and pulsate, and the damming back of 
the blood in the vena cava inferior enlarges the liver to a point of pulsation. 

Tricuspid Stenosis is usually associated with mitral stenosis. The 
rational physical sign is a diastolic murmur in the tricuspid area, with dis- 
tention of the jugular veins and no pulsation. Dropsy occurs at an early- 
period. This condition may be mistaken for mitral stenosis. 



SIGNS AND SYMPTOMS OF VALVULAR LESIONS 351 

Pulmonic Stenosis is congenital and often associated with a patent 
foramen ovale and perforated interventricular septum. The murmur is 
in the pulmonic area and systolic, but such systolic pulmonary murmurs 
are also heard without change in the orifice and valves, viz.: in anaemia. 
A systolic murmur in the pulmonary area is occasionally heard in young 
adults with no other evidence of heart trouble. It is supposed to be due 
to incomplete covering of the" eonus arteriosus by the overlapping lung, 
so that during systole the conus is flattened out against the chest wall, 
forming an eddy in the blood current and thus giving rise to a murmur. 
Other congenital malformations are incomplete interventricular septa, patent 
foramen ovale, persistence of patent ductus arteriosus, transposition of the pul- 
monary artery and aorta, and malformation of the valves. Children and infants 
suffering from such malformations are fretful, may have convulsions, do 
not sleep, have clubbed fingers and toes, are anaemic or cyanotic, remain 
backward in growth and intelligence, and may or may not have murmurs. 

Diagnosis and Prognosis of Congenital Heart Disease 

With a diagnosis of congenital heart disease the prognosis is that many 
die at an early age or of intercurrent disease; some reach eleven, fifteen, or 
twenty-four years (see Psediatrics) . 

Summary of Diagnosis and Prognosis. — The statement will bear reitera- 
tion that a cardiac murmur does not constitute a heart lesion. There are ac- 
cidental and functional murmurs persisting through long life and accidental 
murmurs which appear during a period of relative incompetency in flabby, 
ansemic, neurotic, and fatty subjects or overworked hearts and disappear 
when the heart has regained sufficient tone. A functional intraventricular 
murmur is systolic in time, half way between the apex and the base. It 
is not ansemic and not heard in the neck, and it is due to cardiac debility; 
that is, the papillary muscles fail to contract in unison with the walls of 
the ventricles. It presents no post mortem lesion and frequently disappears. 

When a valvular lesion is strongly suspected and its exact location is 
doubtful, no anxiety need be felt by the medical man as regards its precise 
rational treatment, for it is practically the same in all valvular lesions. 
With an apex beat in normal position and of normal rhythm, no anxiety 
need be felt regarding a murmur. The cure of a heart lesion should not be 
set down as hopeless until iodide of potassium has been tried. 

Regarding prognosis, each case must be judged- on its own merits. 
Small people bear a valvular lesion better than tall and bulky persons, and 
women better than men. Worry aggravates all heart cases, also damp living 
apartments and poverty. Marriage should not be interdicted except in severe 
forms of heart disease. During parturition women often present various con- 
gestive symptoms which pass off after the termination of pregnancy, and 
twenty years of happy married life are better than thirty years of celibacy. It 
is well, however, to warn such patients of the danger of repeated pregnancies. 

Principles of Treatment 

As soon as the diagnosis of valvular heart disease is established, the 
following considerations come up: No dancing for children, except square 
dancing. Rest in bed for choreatic children with murmurs. Sunshine and 



352 THE CIRCULATORY SYSTEM 

good air for rheumatics, no damp living rooms, removal from malarious 
regions. 

The clinical course of valvular heart disease admits of a division into 
three stages , The attainment of compensation, full compensation, and loss 
of compensation. The treatment of such symptoms as arise during the 
three stages is practically the same for all varieties of valvular defects. Until 
compensation is attained the patient will complain of palpitation, occasional 
nausea, short breath, and nervousness. Heart drugs are not indicated at 
this stage. The patient must lead a quiet and orderly life and avoid worry 
and overstrain. Young men should be advised to enter some field of use- 
fulness in harmony with their "weak heart." Severe exercise, such as 
swimming and violent dancing, should be interdicted. The school work 
should be less exacting than for the healthy; girls should rest one or two 
days during menstruation; cool and cold sponge baths are advisable. In 
the way of exercise walking is advisable; moderate bicycle exercise on level 
ground is permissible. Alcohol, coffee, tea, and articles of food apt to pro- 
duce flatulence, such as beans, peas, lentils, doughnuts, rich pastry, and 
Swiss cheese, should be avoided. A narrow diet is not called for. All 
meats may be eaten except pork, all salads except mayonnaise salads, all 
cereals, eggs, ham, fruit, and stale bread; water, mineral water, and ginger 
ale are to be allowed. The stomach should not be overloaded with food 
or liquids. The bowels should move once a day, or an enema of soap 
water shovild be given before the patient goes to bed, occasionally a laxative 
or brisk purge. Maltine with cascara for children is indicated. Ten grains 
of blue mass followed by a Seidlitz powder for adults, once a week, may be 
taken. The underclothing should be of thin wool or linen mesh. Protec- 
tion from cold is best secured by thick outer coats and wraps. 

To aid digestion, 5 drops of hydrochloric acid in sugar water may be 
taken after each meal, or Horsford's acid phosphate in water. Patients 
should be warned against great altitudes and Turkish or Russian baths. 
Long sea voyages are not well borne by damaged hearts. The utmost care 
should be exercised not to contract typhoid fever from contaminated water 
and other sources. Typhoid fever and pneumonia give an unfavorable 
prognosis in patients with weak hearts. Anaesthesia in cases of weak heart 
should be carefully considered. The danger of obesity from indolence and 
overeating should be discussed with the patient. Tobacco in moderation 
is not always harmful, and the author knows of a number of patients, 
including physicians, whose rapid heart quieted down after a mild smoke 
and who attained an age of fifty to sixty with mitral insufficiency persist- 
ing for from twenty to twenty-five years. 

When compensation is broken, as shown by marked dyspnoea, dilated 
heart, irregularity of action, and oedema, the treatment may require cold 
baths, carbonic acid baths, rest in bed with massage and passive motion, 
depletion by the bowels, or venesection when respiration is markedly em- 
barrassed and compression of the upper arm shows the veins standing out 
like whip cords. 

Venesection. — A roller bandage is tightly placed around the arm below 
the shoulder, and the skin over the median vein is disinfected and made 
anaesthetic by injecting a weak cocaine solution. The skin over the vein 



PRINCIPLES OF TREATMENT IN VALVULAR LESIONS 353 

is incised for about an inch, and two catgut ligatures are insinuated under- 
neath the bulging vein. The proximal ligature is tied and the bulging 
vein is then opened; after from six to sixteen ounces of blood have come 
away, the distal ligature is tied and an antiseptic dressing applied to the 
wound. Venesection is often a life saving procedure which is too little 
practised in our days. 

Carbonated Baths as they are given at Bad Nauheim appear to exert 
a beneficial influence on the circulation by slightly stimulating the skin. 
Such baths can be given in the house by making use of lumps of chemicals 
that generate carbon dioxide, or better still, by aerating the bath water 
with carbon dioxide by means of liquid carbon dioxide from a cylinder, 
now obtainable in all large cities and many country districts, as it is largely 
used in drawing beer from the cask.* Mild, general massage, practised 
several times a week, together with passive motion, is a better aid to the 
embarrassed circulation than any form of bath; of course massage can be 
employed in connection with hydrotherapeutics. 

This bath treatment is carried on for from five to six weeks with an in- 
termission once or twice a week. The temperature of the bath is to be about 
95° F. in the first week, and may be as low as 80° F. in the sixth week. The 
baths are brine baths, 2 pounds of sea salt to 50 gallons of water, gradually 
increasing in strength to 10 pounds of sea salt to 50 gallons of water. The 
gas generating chemicals are placed in the bottom of the tub of warm brine. 

Resisted Movements and Carbonated Baths are combined in the treat- 
ment of heart insufficiency as follows: 

The patient makes regular voluntary movements, which are resisted by 
the physician or operator. These movements are quite gentle, and if there 
should be any weariness on the part of the patient, or his breathing gets to 
be rapid, an intermission is given until the equilibrium of respiration or 
pulse is restored. 

The movements are simply flexion, extension, adduction, abduction, and 
rotation of the limbs, neck, and trunk. As a rule, these exercises improve 
both the heart and the circulation. 

Another form of bath for improving the circulation is as follows: The 
patient remains for ten minutes in a tub half filled with lukewarm to cool 
water, in which he moves about gently. This is followed by douching with a 
pailful of cold water, after which the patient is quickly dried and rests on a 
couch for half an hour and then takes a light breakfast and a leisurely walk. 
The careful climbing of moderate elevations is beneficial in the early stage of 
valvular lesions, but mountain climbing is decidedly injurious. 

Where moderate exercise, baths, proper diet, and massage, with the 
occasional administration of ten grains each of calomel and jalap or other 
laxatives, fail to quiet the heart or to aid it in accomplishing its work, we 
are compelled to make use of drugs. 

The sjmaptomatic management of heart cases after all physical and sim- 
ple methods have been tried is as follows: 

For 'palpitation in the first and second stage of valvular disease with a 
strong heart muscle apply an ice bag to the heart, and give sodium bromide, 

* Also sold in small metal capsules. 



354 THE CIRCULATORY SYSTEM 

gr. ■ X to XXX, once or twice a day. Prescribe moderate exercise, a cold 
sponge bath, and tincture of aconite in two drop doses several times a day. 

Palpitation in the third stage, with heart dilatation and dropsy, requires 
venesection and stimulating treatment with digitalis, strychnine, or opium. 
(See chapter on Dropsy.) 

Nausea is a distressing symptom in circulatory failure for which we 
may administer dilute hydrochloric acid in 5 drop doses after eating, or 
Horsford's acid phosphate, 30 drops in water, after eating. In some cases a 
tablespoonful of coca wine after a meal does well. 

Ancemia is a prominent feature in many cases of c